NURSING CARE PLAN
ASSESSMENT
Subjective: “Nahihirapan ako huminga” as verbalized by the patient. Objective: • Use of accessory muscle. Abnormal breath sounds. V/S taken as follows: T: 37.3 P: 82 R: 25 BP: 110/80
DIAGNOSIS
Ineffective airway clearance related to increased production of secretions.
INFERENCE
Bronchial asthma is a chronic inflammatory disease of the airways, associated with recurrent, reversible airway obstruction with intermittent episodes of wheezing and dyspnea. Bronchial hypersensitivity is caused by various stimuli, which innervate the vagus nerve and beta adrenergic receptor cells of the airways, leading to bronchial smooth muscle constriction, hypersecretion of mucus, and mucosal edema.
PLANNING
After 3 days of nursing interventions, the patient will demonstrate behaviors to improve airway clearance.
INTERVENTION
Independent: • Auscultate breath sounds. Note adventitious breath sounds like wheezes, crackles and rhonchi. • •
RATIONALE
Some degree of bronchospasm is present with obstructions in airway and may or may not be manifested in adventitious breath sounds. Elevation of the bed facilitates respiratory function by use of gravity. Precipitators of allergic type of respiratory reactions that can trigger or exacerbate onset of acute episode. Provides patient with some means to cope with or control dyspnea and reduce air tapping. Coughing is most effective in an upright position after chest percussion.
EVALUATION
After 3 days of nursing interventions, the patient was able to demonstrate behaviors to improve airway clearance.
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Elevate head of the bed, have patient lean on overbed table or sit on edge of the bed. Keep environmental pollution to a minimum like dust, smoke and feather pillows, according to individual situation. Encourage or assist with abdominal or pursed lip breathing exercises. Assist with measures to improve effectiveness of cough effort.
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Increased fluid intake to 3000 ml/ day. Provide warm or tepid liquids.
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Hydration helps decrease the viscosity of secretions, facilitating expectoration. Using warm liquids may decrease bronchospasm.
Collaborative: • Administer bronchodilators as prescribed.
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To reduce the viscosity of secretions.