ASSESSMENT DATA PLANNING RATIONALE EVALUATION DIAGNOSIS RATIONALE INTERVENTIONS Subjective: Impaired breathing The bronchial muscles and Short term: INDEPENDENT: INdEPENDENT Short term: “May asthma ine hiya. due to ineffective mucus glands enlarge; thick, After 2 hours of 1. Auscultate breath 1. Some degree of After 2 hours of nursing Ngan ginkukurian hiya airway clearance tenacious sputum is nursing intervention sounds. Note bronchospasm is present intervention the patient paghinga ngan bagat related to produced; and the alveoli the patient will be adventitious breath with obstructions in airway will be able to: may plema niya na dire increased mucous hyperinflate. Some patients able to: sounds such as and may or may not be Participate in activities nagagawas” as secretions and may have airway Participate in wheezes, crackles, manifested in adventitious that promotes breathing verbalized by SO. tenacious subbasement membrane activities that or rhonchi. breath sounds, such as such as breathing Dyspnea secretions. fibrosis. This is called airway promotes breathing 2. Assess and monitor scattered, moist crackles exercises and coughing Anxiety “remodeling” and occurs in such as breathing respiratory rate. (bronchitis); faint sounds, exercise. response to chronic Note inspiratory-to- with expiratory wheezes Chest tightness exercises and inflammation. The fibrotic expiratory ratio. (emphysema); or absent coughing exercise. Maintain breathing and changes in the airway lead 3. Note presence and breath sounds (severe Objective: oxygenation in normal to airway narrowing and degree of dyspnea. asthma) Usage of Maintain breathing range potentially irreversible 4. Assist client to 2. Tachypnea is usually accessory and oxygenation in airflow limitation maintain a present to some degree and muscles normal range Long term: comfortable may be pronounced on RR 34 Source: admission, during stress, or After 2-3 days of nursing position to facilitate HR 160 Medical Surgical Nursing by Long term: breathing by during concurrent acute intervention the patient Weakness Brunner Suddarth 10th After 2-3 days of will be able to: elevating the head infectious process. Ineffective cough edition, pg. 588 nursing intervention Respirations may be Maintain normal the patient will be of bed, leaning on Wheezing shallow and rapid, with performance of over-bed table, or able to: ADLs Crackles sitting on edge of prolonged expiration in Maintain comparison to inspiration Demonstrate stable auscultated on bed. normal 3. Respiratory dysfunction breathing pattern the 5. Encourage and performance is variable depending on the treacheobronchial assist with of ADLs abdominal or underlying process, for area Demonstrate pursed-lip breathing example, infection, allergic stable exercises. reaction, and the stage of breathing 6. Observe for chronicity in a client with pattern. persistent, hacking, established COPD. Note: or moist cough. Using a scale to rate Assist with dyspnea aids in quantifying measures to and tracking changes in improve respiratory distress. Rapid onset of acute dyspnea may reflect pulmonary embolus. effectiveness of 4. Elevation of the head of cough effort. the bed facilitates 7. Increase fluid intake respiratory function using to 3000 mL/day gravity; however, client in within cardiac severe distress will seek the tolerance. Provide position that most eases warm or tepid breathing. Supporting arms liquids. Recommend and legs with table, pillows, intake of fluids and so on helps reduce between, instead of muscle fatigue and can aid during, meals. chest expansion. 8. Limit exposure to 5. Provides client with some environmental means to cope with and pollutants such as control dyspnea and reduce dust, smoke, and air-trapping. feather pillows 6. Cough can be persistent according to but ineffective, especially if individual situation client is elderly, acutely ill, DEPENDENT: or debilitated. Coughing is 1. Artificial surfactant most effective in an upright such as colfosceril or in a head-down position palmitate (Exosurf) after chest percussion. 2. Provide 7. Hydration helps decrease supplemental the viscosity of secretions, humidification, such facilitating expectoration. 8. as ultrasonic Precipitators of allergic type nebulizer and of respiratory reactions that aerosol room can trigger or exacerbate humidifier. onset of acute episode. 3. Provide supplemental Dependent humidification, such 1. Research suggests as ultrasonic aerosol nebulizer and administration may aerosol room enhance humidifier. expectoration of Source: sputum, improve Nursing Care Plans 9th pulmonary Edition pg. 122-124 function, and reduce lung volumes (air- trapping) 2. Humidity helps reduce viscosity of secretions, facilitating expectoration, and may reduce or prevent formation of thick mucous plugs in bronchioles. 3. Breathing exercises help enhance diffusion; aerosol or nebulizer medications can reduce bronchospasm and stimulate expectoration. Postural drainage and percussion enhance removal of excessive and sticky secretions and improve ventilation of bottom lung segments. Note: Chest physiotherapy may aggravate bronchospasm in asthmatics.