NURSING CARE PLAN

NURSING SCIENTIFIC NURSING

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.