Nursing Care Plan

Assessment Diagnosis Nursing Outcome Nursing Intervention Rationale Evaluation

Subjective data Ineffective Breathing Pattern The patient will be able to Assess the client’s vital signs as Increased BP, RR, and HR The patient shall maintain
“I am having a bad asthma r/t swelling and spasm of the maintain optimal needed while in distress. occur during the initial optimal breathing pattern, as
attack. My chest feels very bronchial tubes in response to breathing pattern, as hypoxia and hypercapnia. And evidenced by relaxed
tight and I cannot catch my inhaled irritants, as evidence evidenced by relaxed when it becomes severe, BP breathing, normal respiratory
breath.’’ as verbalized by by dyspnea, high-pitched breathing, normal and HR drops and respiratory rate or pattern, and absence of
the patient wheeze, SpO2 level of 86 % respiratory rate or failure may result. dyspnea
and respiratory rate of 34 pattern, and absence of
dyspnea. Assess the respiratory rate, depth, Changes in the respiratory
Objective data and rhythm. rate and rhythm may indicate
● Dyspnea with an early sign of impending
audible respiratory distress.
high-pitched
wheezing Assess breath sounds and Adventitious sounds may
adventitious sounds such as indicate a worsening condition
● Difficulty speaking wheezes and stridor. or additional developing
● Abnormal breath complications such as
sounds, inspiratory pneumonia. Wheezing
and expiratory happens as a result of
wheezing bronchospasm. Diminishing
wheezing and indistinct
V/S taken as follows: breath sounds are suggestive
● R-34 bpm findings and indicate
● BP-142/96 mmHg impending respiratory failure.
● O2-86 %
Assess for signs of dyspnea These indicate respiratory
(flaring of nostrils, chest distress. Once the movement
retractions, and use of accessory of air into and out of the lungs
muscle).

Monitor oxygen saturation.
Monitor arterial blood gasses
(ABG).
Maintain head of bed elevated.
Encourage client to use pursed-lip
breathing for exhalation.
becomes challenging, the
breathing pattern changes.
Oxygen saturation is a term
referring to the fraction of
oxygen-saturated hemoglobin
relative to the total
hemoglobin in the blood.
Normal oxygen saturation
levels are considered
95-100%.
During a mild to moderate
asthma attack, clients may
develop respiratory alkalosis.
Hypoxemia leads to increased
respiratory rate and depth,
and carbon dioxide is blown
off. An ominous finding is a
respiratory acidosis, which
usually indicates that
respiratory failure is pending
and that mechanical
ventilation may be necessary.
This promotes maximum lung
expansion and assists in
breathing.
Pursed lip breathing improves
breathing patterns by moving
old air out of the lungs and
allowing for new air to enter
the lungs.
Administer medication as
ordered:

Short-acting beta-2-adrenergic
agonist.
● Albuterol (Proventil, Short-acting beta2-agonists
Ventolin). are bronchodilators. They
● Levalbuterol (Xopenex). relax the muscles lining the
● Terbutaline (Brethine). airways that carry air to the
lungs; treatment of choice for
Inhaled Corticosteroids. acute exacerbation of asthma.
● Budesonide (Pulmicort).
● Fluticasone (Flovent). Corticosteroids reduce
● Beclomethasone inflammation in the airways
(Vancenase). that carry air to the lungs and
● Mometasone (Asmanex reduce the mucus made by
Twisthaler). the bronchial tubes. Inhaled
steroids should be given after
beta-2-adrenergic agonist.