RICARDO BAUTISTA BSN-3D

NURSING CARE PLAN

ASSESSMENT
Subjective: Hindi ako masyadong makahinga as verbalized by the patient. Objective: - Persistent coughing with blood streak sputum - Inhalation @ 2L per min via nasal cannula, prn - RR- 24 - Nebulization Salbutamol PRN - Wheezing - Rhonchi upon auscultation - Use of accessory muscles - Decreased cough reflex - Impression of: Bronchial Asthma 16-20 bpm

Nursing Diagnosis
Ineffective Airway Clearance related to increase production of secretions secondary to Bronchial Asthma Inability to clear secretions or obstructions from the respiratory tract will cause ineffective airway clearance.

Scientific Explanation
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
within 8 hrs of nursing care, the patient will be able to improve airway clearance as manifested by: a. cough effectively and expectorate secretions b. clear breath sounds upon auscultation c. RR with in normal range of 16-20 bpm

Nursing Intervention
1. Auscultate breath sound. Note adventitious breath sounds.

Rationale
some degree of bronchospasm is present in obstructions in airway and may or may not be manifested in adventitious breath sounds. tachypnea is usually present to some degree and may be pronounced on admission or during stress/ concurrent acute infectious process. Respiration may be shallow and rapid, with prolonged expiration in comparison to inspiration. respiratory dysfunction is variable depending on the underlying process. elevation of the head

Evaluation
After 8 hours of nursing care The patient was able to cough out secretions. RR of 19 within the normal range.

2. Reassess or monitor respiratory rate

3. Note presence/ degree of dyspnea

4. Place patient in Moderate high Back

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Rest. of the bed facilitates respiratory function by use of gravity; however, patient in severe distress will seek the position that most eases breathing. Supporting arms or legs with pillows helps reduce muscle fatigue and can aid chest expansion.

5. Keep environmental pollution to a minimum like dust, smoke and feather pillows.

Precipitators of allergic type of respiratory reactions that can trigger/ exacerbate onset of acute episode. Cough can be persistent but ineffective, especially if patient is elderly, acutely ill, or debilitated. Coughing is most effective in an upright or in a head down position after chest precaution.

6.Observe characteristics of cough and assist with measure to improve effectiveness of cough effort.

7. Encourage deep breathing exercise

Provides patient in some means to cope with/ control dyspnea and reduce air trapping.

8.

Administer

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medications as prescribed by the doctor (e.g. bronchodilators) 9. Provide fluids within individual capacity. helps expectorate secretions.

helps liquefy secretions, enhancing experctoraion

10. Encourage or assist with abdominal or pursed lip breathing exercises.

Provides patient with some means to cope with or control dyspnea and reduce air tapping.