NURSING CARE PLAN

Name of Patient: Attending Physician:

Age: Impression/Diagnosis:
 Clustered Cues Nursing Diagnosis Rationale Outcome Criteria Interventions Rationale Evaluation
04/20/10 11:00 am INDEPENDENT: 04/20/10 3:00 p.m
Ineffective The physiologic The client will be
Client refrains from Breathing Pattern changes in lung able to establish an 1. Frequently assess Early identification GOAL PARTIALLY
talking because he related to ventilation that effective respiratory respiratory rate, of ineffective MET.
finds it hard to bronchospasm, occur during an pattern so as to pattern, and breath respirations allow The client
breathe while doing decreased lung acute asthma provide adequate sounds. Note timely initiation of manifested
so. expansion attack impair both ventilation as manifestations of interventions. decreasing
lung expansion and manifested by ineffective respiratory rate,
Client simply points emptying. Anxiety stabilizing breathing. RR=22
out objects he caused by hypoxia respiratory rate, Tachypnea, breaths/minute and
wants and makes and dyspnea decreasing chest 2. Monitor vital tachycardia, an appeared less
signs because he compounds the tightness, slight to signs and laboratory elevated blood strained and
finds it difficult to problem by no nasal flaring and results. pressure, and distressed upon
breath. increasing the decreasing usage of increasing breathing. However,
respiratory rate. accessory muscles hypoxemia and wheezes can still be
Complains of tight by 04/20/10 3:00 hypercapnia are auscultated from all
feeling in the chest PATHOPHYSIOLOGY p.m. signs of lung fields and there
When a trigger such compromised is still usage of
RR=37 as inhalation of an respiratory status. accessory muscles
breaths/minute allergen or irritant 3.Assist with self- and nasal flaring.
occurs, an acute or care activities. This conserves
With rapid and early response energy and reduces
shallow respirations develops in the 4. Provide rest fatigue.
hyperreactive periods between
Uses accessory airways predisposed scheduled activities Scheduled rest is
muscles to aid in to bronchospasm. and treatments. important to
breathing Sensitized mast prevent fatigue and
cells in the 5. Place in Fowler’s, reduce oxygen
Exhibits nasal bronchial mucosa High Fowler’s or demands. .
flaring release orthopneic (with
inflammatory head and arms These positions
ABG Results mediators such as supported on the reduce the work of
04/20/10 histamine, overbed table) breathing and
HCO3= 23.2 mmol/L prostaglandins and position to facilitate increases lung
O2 Sat= 97.9% leukotrienes. These breathing and lung expansion,
pH= 7.501 mediators stimulate expansion. especially the
pCO2= 29.8 mmHg parasympathetic basilar areas.
Impression: receptors and 6. Teach and assist
Respiratory bronchial smooth to use techniques to
Alkalosis without muscle to produce control breathing
compensation bronchoconstriction. pattern: Pursed- lip
They also increase a. Pursed-lip breathing helps
capillary breathing keep airways open
permeability, b. Abdominal by maintaining
leading to mucosal breathing positive pressure,
edema, and c. Relaxation and abdominal