GROUP 1 NCP (ASTHMA) EMERGENCY NURSING

Assessment Background Diagnosis Planning Intervention Rationale Evaluation

knowledge
Subjective Data: Asthma is a chronic Ineffective After 3 hours of Independent After 3 hours of
n/a inflammatory lung airway nursing Nursing nursing
disease that causes clearance intervention, the Intervention: intervention, the
Objective Data: airway related to patient will -Monitor patient’s -As baseline data for patient didn’t
-Dyspnea hyperresponsiveness, bronchospasm exhibit optimal vital signs the effectiveness of exhibit optimal
-Shortness of mucus production, as manifested breathing continuously treatment. Drop in breathing pattern,
breath when and mucosal edema by dyspnea, pattern, as especially BP, RR and BP and HR indicates as evidenced by
trying to talk resulting in shortness of evidenced by HR and O2 saturation. worsening condition intermittent
-Tachypnea reversible airflow breath when relaxed and may result to respiratory distress
-Tachycardia obstruction. Patient talking, breathing, respiratory failure. with poor air
-Restlessness was exposed to an tachypnea 28 normal RR of movement and
-Adventitious allergen, an bpm, 20 bpm, and stridor.
lung sounds immediate tachycardia 124 absence of -Place client on semi- -Promotes lung
(wheezes) inflammatory bpm, dyspnea. fowler’s and limit expansion and assist Goal not met.
response with restlessness and movement. breathing. Limiting
Vital signs taken bronchospasm adventitious movement prevents Patient is
as follows: happens. This lung sound increase metabolic transferred to the
T: 36.4 inflammatory wheezes. rate and O2 demand. ICU.
HR: 124 bpm process leads to
RR: 28 bpm recurrent episodes of
BP: 130/90 asthmatic symptoms Dependent Nursing
such as cough, Intervention:
dyspnea, wheezing,
and increased mucus -Administer O2 -Increase oxygen
production. inhalation 1-2 liters saturation to prevent
per minutes as hypoxia.
prescribed.
-Administer -Helps relax the
bronchodilators such muscle bands that
as nebulized albuterol tighten around the
10-20mg/hr, airways.
nebulized ipratronium
bromide 500 mcgq20
minutes for 3 doses)

-Administer IV -Stronger than

methylprednisolone. prednisone, helps to
relieve severe asthma
exacerbations.