A Nursing Care Plan on

ASTHMA

In Partial Fulfillment of the

Requirements on NCM 212 RLE

Immunology & Cancer Nursing Rotation

Submitted to:
Gemshe M. Santos, RN
Clinical Instructor

Submitted by:
John Cyprian A. Abelo

BSN 3L - GROUP 2
September 29, 2021
NAME: Jojo O’Neal Age/Sex: 55/F Room&Bed: 202-
Chief Complaint: Difficulty of Breathing Physician: Dr. Agpayan
Diagnosis: Asthma
DATE CUES NEED NURSING PAITENT NURSING IMPLEM EVALUATION
DIAGNOSIS OUTCOME INTERVENTION ENTATI
ON
S Subjective: A Ineffective Within 2 hours, the Assess the client’s 1 09/29/2021
E “Nurse, naglisod C breathing pattern Patient will vital signs as 10:00 AM
P kog ginhawa. T related to maintain optimal needed while in
T Ganiha pa pud ko I presence of breathing pattern, distress. “Goal met”
2 sigeg luwa ug V secretions as as evidenced by R: Increased BP,
9, plema” as I evidenced by relaxed breathing, RR, and HR occur After applying the
verbalized by the normal respiratory nursing intervention
T productive cough during the initial
patient last August rate or pattern, and in in the past 2
2 Y and dyspnea. hypoxia and
29, 2021 at 7:30 absence of hours, the patient
0 / dyspnea. hypercapnia. And
am. was able to maintain
2 E when it becomes
optimal breathing
1 X Rationale: severe, BP and HR
pattern, as
@ E Presence of drops and evidenced by
8 R secretions in the respiratory failure relaxed breathing,
Objective:
A C bronchi will result may result. normal respiratory
• wheezing
M I into a blockage of rate or pattern, and
upon
S air that will enter Assess the absence of dyspnea.
inspiration
E the body and thus respiratory rate, 2
and
producing depth, and rhythm. “salamat sir, okay-
expiration
insufficient air R: Changes in the okay na akong
• dyspnea
needed by the respiratory rate and paghinga karon ug
• coughing,
body. And inability rhythm may indicate relax na kaayo ko
sputum is
to maintain clear an early sign of makatulog nako
yellow and
airway. This impending balik”, as verbalized
sticky
obstruction is respiratory distress. by the patient.
tachypnea,
 prolonged further heightened
expiration by bronchospasm Assess the client’s
• tachycardia due to the level of anxiety. 5
• chest contraction of the R: Anxiety may John Cyprian A.
tightness smooth muscles result from the Abelo, St. N
inthe bronchi. This struggle of not
is caused by being able to
parasympathetic breathe properly.
stimulation of
themuscarinic2 Assess breath
receptors as well sounds and 3
as by chemical adventitious sounds
mediators such as wheezes
released in and stridor.
response to the R: Adventitious
presence of sounds may
allergen. indicate a
worsening condition
or additional
developing
complications such
as pneumonia.
Wheezing happens
as a result of
bronchospasm.
Diminishing
wheezing and
indistinct breath
sounds are
suggestive findings
and indicate
impending
respiratory failure.

Monitor oxygen
saturation.
R: Oxygen 4
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%.

Encourage
coughing. Suction
secretions as
needed. 6
R: To help clear
thick phlegm that
the patient is unable
to expectorate.
Maintain head of
bed elevated.
R: This promotes
maximum lung 7
expansion and
assists in breathing.

Encourage client to
use pursed-lip
breathing for
exhalation. 8
R: Pursed lip
breathing improves
breathing patterns
by moving old air
out of the lungs and
allowing for new air
to enter the lungs.

Administer the
prescribed asthma
medications (e.g.
bronchodilators,
steroids, or 9
combination
inhalers /
nebulizers).
R: Bronchodilators:
To dilate or relax
the muscles on the
airways. Steroids:
To reduce the
inflammation in the
lungs.

Anticipate the need

for alternative
treatment if life-
threatening
bronchospasm
continues such as 10
magnesium sulfate.
R: Magnesium
sulfate has
bronchodilating and
anti-inflammatory
effects that are
sometimes used in
the treatment of
moderate to severe
asthma in children.