NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Independent:
Subjective:
�Nahihirapan ako
Ineffective
airway
clearance
Bronchial asthma is
a chronic
After 3 days of
nursing
interventions,
� Auscultate breath
sounds. Note
adventitious
� Some degree of
bronchospasm
is present with
After 3 days of
nursing
interventions,
huminga� as
verbalized by the
patient.
Objective:
� Use of
accessory
muscle.
� Abnormal
breath
sounds.
related to
increased
production of
secretions.
inflammatory
disease of the
airways, associated
with recurrent,
reversible airway
obstruction with
intermittent
episodes of
wheezing and
dyspnea. Bronchial
hypersensitivity is
caused by various
the patient will
demonstrate
behaviors to
improve airway
clearance.
breath sounds
like wheezes,
crackles and
rhonchi.
� Elevate head of
the bed, have
patient lean on
overbed table or
sit on edge of the
bed.
� Keep
environmental
obstructions in
airway and may
or may not be
manifested in
adventitious
breath sounds.
� Elevation of the
bed facilitates
respiratory
function by use
of gravity.
� Precipitators of
allergic type of
the patient was
able to
demonstrate
behaviors to
improve airway
clearance.
� V/S taken as stimuli, which pollution to a respiratory
follows: innervate the vagus minimum like reactions that
T: 37.3
P: 82
R: 25
nerve and beta
adrenergic receptor
cells of the airways,
dust, smoke and
feather pillows,
according to
individual
can trigger or
exacerbate
onset of acute
episode.
BP: 110/80 leading to bronchial situation.
smooth muscle � Encourage or � Provides patient
constriction, assist with with some
hypersecretion of
mucus, and
mucosal edema.
abdominal or
pursed lip
breathing
exercises.
means to cope
with or control
dyspnea and
reduce air
� Assist with
tapping.
� Coughing is
measures to
improve
most effective
in an upright
effectiveness of
cough effort.
position after
chest
percussion.
� Increased fluid
intake to 3000 ml/
day. Provide
warm or tepid
liquids.
Collaborative:
� Administer
bronchodilators
as prescribed.
� Hydration helps
decrease the
viscosity of
secretions,
facilitating
expectoration.
Using warm
liquids may
decrease
bronchospasm.
� To reduce the
viscosity of
secretions.
� Increased fluid
intake to 3000 ml/
day. Provide
warm or tepid
liquids.
Collaborative:
� Administer
bronchodilators
as prescribed.
� Hydration helps
decrease the
viscosity of
secretions,
facilitating
expectoration.
Using warm
liquids may
decrease
bronchospasm.
� To reduce the
viscosity of
secretions.