Nursing Diagnosis-1

Ineffective Breathing Pattern Related To Swelling and spasm of the bronchial tubes in
response to inhaled irritants, infection, drugs, allergies or infection.

Nursing Interventions

Assess the client’s vital signs as needed while in distress.

Assess the respiratory rate, depth, and rhythm.

Assess the client’s level of anxiety
Assess breath sounds and adventitious sounds such as wheezes
and stridor.
Ineffective Breathing Pattern

Nursing Interventions

Assess the relationship of inspiration to expiration.

Assess for signs of dyspnea (flaring of nostrils, chest retractions, and use of
accessory muscle).

Assess for conversational dyspnea.

Assess for fatigue

Assess the presence of paradoxical pulse of 12 mm Hg or greater.

 Ineffective Breathing Pattern

Nursing Interventions

Monitor oxygen saturation.

Monitor arterial blood gasses (ABG).

Administer mediaction as ordered:
•Short-acting beta-2-adrenergic agonist.Albuterol (Proventil, Ventolin).
•Levalbuterol (Xopenex).
•Terbutaline (Brethine).
 Nursing Diagnosis-2.
Ineffective Airway Clearance Related to Bronchospasms
Nursing Interventions

Assess respiratory rate, depth, and rhythm.

Assess for color changes in the buccal mucosa, lips, and nail beds.

Auscultate lungs for adventitious breath sounds (wheezes and rhonchi).

Assess the effectiveness of cough.

. Monitor oxygen saturation using pulse oximetry.

 Nursing Diagnosis-3
Deficient Knowledge Related to Chronicity of disease

Nursing Interventions and Rationales

Nursing Interventions
Assess the client’s knowledge of care for status asthmaticus, as appropriate.

Assess past and present therapies, including the client’s response to them.

Assess the client’s knowledge of asthma triggers and asthma medications:

 Treatment for status asthmaticus.
 Correct use of metered-dose inhaler (MDI) and space.
 Use of spacers with an MDI.
 Ability to distinguish between rescue medications and controllers.