Assessment Data for Nursing Diagnosis Subjective: Mom says the child has been breathing with difficulty

and very fast. In addition he became very agitated and distressed when walking to the bathroom according with Moms statement. Objective:

Nursing Diagnosis Collaborative Problems

Expected Outcomes with Indicators Short Term: The client will demonstrate improved ventilation, adequate oxygenation and will be free of respiratory distress when walking by the end of the shift.

Nursing Intervention 1-Monitor respiratory rate, depth , and effort, including use of accessory muscles, nasal flaring and abnormal breathing patterns. 2- Auscultate breath sounds every 1-2 hrs or prn and be alert for crackles and wheezes that could indicate airway obstruction and increase the difficult breathing. 3- Monitor oxygen saturation continuously using pulse oximetry. Monitor ABGs labs values if available and chest X-rays 4- Position the client in semi-Fowlers position, with an upright posture at 45 degrees if possible.

Scientific Rationale Increased respiratory rate, use of accessory muscles, nasal flaring, abdominal breathing, and a look of panic in the clients eyes may be seen with hypoxia. (Ackley, 2006, p.558) In severe exacerbations, lungs sounds may be diminished or distant with air trapping. (Ackley, 2006, p.558)

1- Impaired gas exchange r/t ventilationperfusion imbalance AEB diminished PsO2 readings and SOB.

Evaluation/Effectiveness of Nursing Intervention The respiratory rate increased in relation with previous measurement to 25 respirations per minute. It is necessary to continue being monitored this vital sign. The expiratory wheezing detected earlier wasnt present when examined at the end of the shift. It needs to continue monitoring for a possible return. Saturation of O2 improved from 91% to 93% during shift, but it needs to reach more reassuring levels.

-PR: 112 at rest (Normal PR 70-110 at rest) - Increased heart rate when walking to bathroom: HR= 186 and distress - Increased RR: 25 ( Normal17-21) -S02: 91% (at 10 AM)-room air 93% (at 3 PM)- room air - Chest X-ray (11-042012): multiple small patches of atelectasis bilaterally. No consolidation. - Decreased breath sounds at the bases bilateral. - Expiratory wheezing in right upper/medium lobes - Substernal retraction. Long Term: The child and family will implement a daily treatment plan for asthma and reduce the number of asthma episodes, as long as possible (and doing so avoiding hospital admissions) by 1 month.

An oxygen saturation of less than 90% (normal: 95 to 100%) indicates significant oxygenation problems. (Ackley, 2006, p.558) Research done on clients on a ventilator demonstrated that being in a 45 degree upright position increased oxygenation and ventilation. Research on healthy subjects demonstrated that sitting upright resulted in higher tidal volumes and minute ventilation versus sitting in a slumped posture. (Ackley, 2006, p.558) Oxygen has been shown to correct hypoxemia , which can be caused by retained secretions). (Ackley, 2006, p.167) The goal of inpatient oxygen therapy for a client with asthma is to keep an oxygen greater than 95% to maintain cellular oxygenation. (Ackley, 2006,

The client while on bed was positioned in semi-Fowlers position, and he manifested being comfortable and breathing better in comparison to a lower position on the bed.

5- Administer and assess response to oxygen for respiratory distress. Provide humidified oxygen through an appropriate device ( nasal canula or Venturi mask per physician order).

The client needed to use oxygen once during shift because his SOB. When he walks outside of his room he carries his O2 thank. His SOB needs to continue being monitored and continue providing O2 as necessary.

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