NURSING CARE PROCESS

Name of Patient: Patient AJ. Age: 7 y/o Sex: Male Civil Status: Single

Medical /Surgical Diagnosis: Acute Asthma Assessment date: December 2, 2021 Intervention date: December 3, 2021

Prepared by: Sumbilla, Irish Anne B. Section/Grp No: BSN 310, Group 4 CI/Supervisor: Prof. Perla Lachica

NURSING
CUES ANALYSIS GOAL INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective cues: Ineffective Scientific Analysis: Short-term Goal: [MET]
(hypothetical) Airway After 2 hrs of nursing
 The mother Clearance When the muscles intervention the a. Effectiveness –
of the patient RT airway surrounding the patient will maintain After 4 hours of
verbalized, obstruction bronchial tubes tighten, optimal breathing nursing
“Ubo po siya AEB non- restricting pattern, as evidenced intervention, the
ng ubo pero productive airflow, acute asthma, by relaxed breathing, patient was able
wala naman cough also known as "asthma normal respiratory to maintain
pong plema attack" or "acute rate or pattern, and optimal breathing
na kasama. asthma absence of pattern.
Makati daw exacerbation," develops adventitious breath b. Efficiency – All
po ito sa . sounds. of the
pakiramdam. intervention
” In children, acute followed the
asthma exacerbations standards of care
Objective cues: are characterized by an accordingly as
 Adventitious acute or subacute onset independent,
breath of wheezing and dependent, and
sounds respiratory distress, with collaborative
(inspiratory symptoms and interventions.
and indications that differ c. Adequacy – All
the interventions
 expiratory depending on the child's met the patient's
wheezes) developmental and needs, which was
 Increased maturational age. manifested by
respiratory relaxed breathing,
rate Potential precipitating normal
 Non- factors are inhaled respiratory rate or
productive allergens, environmental pattern, and
cough irritants, stress, absence of
medications, and poor adventitious
preventative therapy breath sounds.
adherence. d. Appropriateness
– All
Situational Analysis: interventions are
relevant and
The E.R. admits a 7- significant to
year-old patient. He's meet the patient's
afebrile and tachypneic, needs.
with a respiratory rate of e. Acceptability –
36 breaths per minute All interventions
and ineffective cough. were
He got a cold recently. demonstrated by
The client may have the patient with
ACUTE Asthma based full cooperation
on his medical history. and compliance.
Inspiratory and Objectives:
expiratory wheezing is
present at the time of Cognitive [MET]
assessment. 2 days ago,  The patient’s  Briefly explain  To help patient
he was exposed to family will the Etiology of and parents to  After nursing
gasoline and fumes. He verbalize asthma in understand intervention, the
had inspiratory and awareness of layman’s terms what triggers patient’s parents
expiratory wheezes and causative factors. to the parents of asthma attacks was able to
a decreased expiratory the patient. and how to verbalize
volume and needed to avoid those awareness of
be treated straight soon situations. causative factors.
with the prescription
listed below.
Bronchodilators were
provided to him as an  By providing [MET]
emergency measure. health education  Listen to the  The parents’
for patient / family’s concerns may  After nursing
parents regarding concerns about not be the same intervention, the
use of asthma as the nurse’s. patient’s parents
maintenance management If the parents’ were able to
medications they and respond concerns are verbalize use of
would know how with not addressed, maintenance
to recognize and information to the parents may medications and
avoid triggers. correct any not comply how to recognize
misconceptions. with and avoid
recommended triggers.
care.
 Teach the
family skills  Proper use of
(assessment, equipment and
use of appropriate
equipment, and medication
giving dosage will
medications) help alleviate
for managing asthma
the child’s symptoms.
asthma attacks.

Psychomotor
 Patient will have
adequate air  Assess [MET]
exchange and respiratory
respiratory status. status  Get a baseline  After nursing
to determine intervention, the
effectiveness of patient was able
interventions to experience
and course of adequate air
 Assess the treatment. exchange and
patient’s respiratory status.
characteristics  Changes in the
of respiration at respiratory rate
least every 4 and rhythm
hours. may indicate an
early sign of
impending
respiratory
 Assess breath distress.
sounds via
auscultation.  Adventitious
sounds may
indicate a
worsening
condition or
additional
developing
complications
such as
 Administer pneumonia.
Bronchodilators
as prescribed  Bronchodilators
by the are a type of
physician. medication that
 make breathing
easier by
relaxing the
muscles in the
lungs and
widening the
airways
(bronchi).
 Patient will [MET]
demonstrate
absence/reduction  Teach about the  After nursing
of congestion coughing, deep  This lets intervention, the
with breath breathing, and trapped air get patient was able
sounds clear, and relaxation out of the air to demonstrate
noiseless techniques. sacs. absence/reduction
respirations. of congestion
 Administer with breath
Fluticasone  Inhaled sounds clear, and
Propionate fluticasone and noiseless
salmeterol as salmeterol is respirations.
prescribed by used to prevent
the physician. asthma attacks
and to treat
chronic
obstructive
pulmonary
disease
Affective (COPD).
 The patient’s [MET]
parents will
understand  Assist parents  After nursing
coping strategies and providers  This plan intervention, the
to handle their in creation of outlines the patient’s parents
child’s asthma. Asthma Action patient’s known was able to
Plan for school. triggers and understand
how to manage coping strategies
symptoms that to handle their
arise. If the child’s asthma as
patient is evidenced by
required to take creating asthma
maintenance or action plan for
rescue school.
medications
during school
hours, this plan
outlines the
importance of
that treatment
and how to
administer
those
medications.
 Educate the
parents about  Parents need
when to call for guidelines for
future medical judging the
advice or to severity of
seek emergency asthma attacks.
treatment.

 Give Vitamin
B12 as  The B-complex
prescribed by vitamins act as
the physician. coenzyme and
 are essential for
the metabolism
of proteins,
carbohydrates,
and fatty acids.
 Give Iron
Dextran as  The IV
prescribed by administration
the physician. of iron dextran
is for iron
repletion in
children who
are unable to
tolerate
feedings
because of
malabsorption,
inflammatory
bowel disease,
or chronic
debilitating
diseases.