Time Objectives Contents Teacher Learner’s Evaluation

Activity Activity
2mins Ice breaker Teacher will Students will
1
INTRODUCTION ask students to attempt to identify
identify the the main theme in
main theme in the scenario (by
The nursing process is a series of steps nurses take to assess patients, plan for and provide the scenario looking at the
patient care, and evaluate the patient’s response to care. It is considered the framework
upon which all nursing care is based. and how it picture) and how it
relates to the relates to the topic
topic to be to be taught
taught
3mins Define the A systematic, rational, modified scientific method of planning and Teacher will Students will Students will
term providing individualized nursing care. (Funnell, Koutoukidis & randomly ask attempt to define correctly
Nursing Lawrence, 2009) students to the nursing process define the
process define the in their own terms the
terms the words. nursing
nursing process
process in their utilizing at
own words. least two
words
according to
Teacher will Students will sit the context
define the and listen such as: A
terms the attentively as term systematic,
nursing the nursing process rational
process with is defined method of
the aid of planning and
PowerPoint providing
according to individualize
the content d nursing care

Teacher will Student will define

ask one student the term nursing
to define the process according
term the to the content
nursing using at least two
process key words such as:
according to A systematic,
the content rational method of
planning and
providing
individualized
patient care
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CAREPLAN

Assessment Diagnosis Patient Intervention and Rationales Evaluation/Outcomes

Objective/Goal
Client has SOB, Ineffective Breathing Within ½ hour of 1. Assess respiratory status lung (What is hoped to be
achieved)
Dyspnea, Use of Pattern related to nursing and other sounds, respiratory rate and
Outcome Criteria:
accessory muscles, trachea-bronchial interventions client depth, presence and severity of
Client will verbalize
thick viscous obstruction/inflammator will demonstrate an wheezing, breathing pattern, use
reduction or absence
secretions. y process as evidence by improvement in of accessory muscles - Some
in difficulty in
Assessment SOB, use of accessory respiratory rate as degree in bronchospasm is
breathing and feeling
revealed muscles, V/S P100bpm, evidence by present with obstruction in
of chest constriction,
V/S P100Bpm, R32bpm, BP 100/65 respiratory rate of 16- airway and may be manifested
respiration and cardiac
R32Bpm, BP 24bpm with wheezing or absent breath
rate within normal
100/65 sounds in severe asthma.
range, absence or
Diagnosis of Acute Ineffective Airway Client will Tachypnea is usually present to
reduction of
Asthmatic attack Clearance related to demonstrate signs of some degree and respiratory
inspiratory and
inflammatory patent airway and dysfunction is variable depending
expiratory wheezing
process/excess mucous adequate oxygen on underlying process such as
following nursing and
production as evidence exchange within the allergic reaction
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by thick viscous 8hr shift following 2. Assess then monitor V/S – other interventions
secretions, Dyspnea, use nursing and other Initially for baseline and then for
of accessory muscles interventions comparison
3. Administer Humidified Oxygen
2-5l as required – to improve
tissue oxygenation and prevent
drying of the nares
4. Assist patient to assume to
comfortable position, i.e. elevate
head of bed, (fowler’s position)
have client lean on over bed table
or sit on the edge of bed -
Elevation of head of the bed
facilitates respiratory function by
use of gravity, however client in
distress may seek position that
most eases work load of
breathing.
5. Keep environmental pollution to
a minimum according to
individual situation - Precipitators
of allergic type of respiratory
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reactions that can trigger or

exacerbate onset of acute episode.
6. Encourage and assist abdominal
and pursed – lip breathing
exercises - Provides some means
to cope with or control dyspnea
and reduce air trapping.
7. Increase fluid intake to 2500-
3000ml within cardiac tolerance -
Hydration helps thin secretions,
facilitating expectoration and
using warm liquids may decrease
bronchospasm.
8. Provide warm liquids and
recommend intake of fluids
between meals, instead of during
meals - Fluids during meals can
increase gastric distension and
pressure on the diaphragm.
9. Administer medications as
indicated. (Atrovent) -
Anticholinergic medications are
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the first line drugs for clients with

this condition.
10. Monitor side effects of
bronchodilator (Salbutamol) –
Bronchodilators are known to
cause (tremors/ tachycardia,
bronchospasm).
11. Provide supplemental
humidification, e.g., nebulizer in
respiratory treatments - Humidity
helps reduce viscosity of
secretions, facilitating/stimulate
expectoration, and reduce
bronchospasm
12. Monitor ABGs, pulse oximetry,
chest x- ray, capillary refill –
indicates acid-base balance,
oxygen saturation levels, level of
obstruction and Establishes
baseline for monitoring
progression/ regression of disease
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process

(Ackley & Ladwig, 2010)