Care Plan Template

Patient Name: Orla O’Donnell

Date of Birth: 22 year old

Assessment Nursing Diagnosis/Problem Goal ( SMART) Interventions with rational ( what actions will be required to address the identified problem)
(remember ‘PES’)

S  Rapport establishment to attain patient’s trust so that the patient is more open with discussions
 Relaxation and breathing exercises as it should have a relaxing and soothing effect, and provide a calm,
Subjective data: P •Reduction of inflammation of controlled breathing in an emergency. There are certain exercises designed to make breathing easier in an
the bronchial mucosa emergency. These include techniques for calm and controlled breathing during asthma attacks. Due to
 Anamnesis  Recurrent chest pain, restlessness and anxiety it can come in such situations to a fast and superficial breathing
 Chest pressure, dyspnea and tightness •Reduction of bronchial (hyperventilation). Even with a stronger asthma attack, most people are still able to breathe relatively well,
pain and  Cyanosis hypersensitivity but exhaling can be very tedious. In asthma training, breathing techniques such as the “lip brake” can be
tightness  Insomnia taught by the nurse (in which one presses the lips together and exhales slowly through a small gap).
 Anxiety •Reduction of airway narrowing  interval training can prevent exertional asthma due to sports, as in interval training, stress and recovery
phases alternate
M
E  counselling to encourage relaxation exercises
Objective data:  Patient education: The importance of patient education cannot be emphasized enough. Patients do better
 Recurrent asthma  Lara Asthma
when they know more about asthma - what triggers an attack, what medicine to use when, proper
 Tripod position Symptom Scale
inhalation technique, how to use a spacer with a metered-dose inhaler (MDI), and the importance of early
 Pursed lip S (LASS)
use of corticosteroids in exacerbations .
breathing
 Blue lips/fingers  Patient verbalisation A
 Low pulse  Mild to moderate persistent
oximetry (< 90) asthma attack Relieving and management of
asthma
 Wheezing  Dyspnea
 Tachypnea  Tachypnea
R
 Anxiety  FEV1 =/> 80%
 Insomnia  Respiratory rate is 19 Patient is to abide by the
 Low blood pressure medication regime

T
Assessment:
1 to 3 months
 Lara Asthma
Symptom Scale
(LASS)
 Asthma Control
Test

PMX:

 Patient history
Evaluation

Patient will:

 demonstrate diaphragmatic breathing and pursed-lip breathing.

 show signs of reduced AEB, nonappearance of dyspnea and respiratory effort
 verbalize better understanding of activities that would progress breathing pattern