NURSING OUTCOME

NURSING DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION

ASSESSMENT IDENTIFICATION

“ Nahihirapan pong Intermittent asthma The patient will After the nursing Independent: Goal met.
huminga ang aking with exacerbation maintain an optimal intervention the  Auscultate
anak at inuubo pa” As related to pulmonary breathing pattern, as patient will maintain breath sounds. The patient’s airway is
verbalized by the hyperinlation demonstrated by optimal breathing patent and free of
patients mother. relaxed breathing and pattern, as evidenced This is to detect secretions, as
a normal respiratory by relaxed breathing, decreased or evidenced by clear
rate or pattern. normal respiratory adventitious lung sounds, and
Objective: breath sounds ability to effectively
rate or pattern and
 Wheezing heard know the foods to cough up secretions
on auscultation avoid that trigger the  Place patient after treatments and
 The rest of the asthma. with proper body deep breaths
exam is within alignment for teachings.
normal limits maximum
 Abdomen is soft breathing
with pattern.
normoactive
bowel sounds A sitting position
 Heart sounds permits
are tachycardic maximum lung
with murmur excursion and
Vital signs takes as chest expansion
follows :
 Assess the
BP: 118/77
patient’s
T-38.2 C
respiratory
RR-28
status by
PR: 128 bpm
monitoring
the severity of
 symptoms,
breath sounds

Changes in the
respiratory rate
and rhythm may
indicate an early
sign of
impending
respiratory
distress.

 Encourage deep
breathing and
coughing.

 Keep patient
environmental
free from source
of allergens such
as dust and
smoke.

Precipitators of
allergic type of
respiratory
reactions that
can trigger or
exacerbate onset
of acute episode.
  Avoid the patient
to eat frozen
foods.

Good nutrition
can strengthen
the functionality
of respiratory
muscles.

Dependent:
 Administer
medications
(bronchodilators)
as prescribed
and monitor
patient’s
responses to
medications.

MAURINE M. PALADIN

ASSESSMENT NURSING OUTCOME

PLANNING INTERVENTION EVALUATION
DIANOSIS IDENTIFICATION
Subjective: Ineffective airway The client will be able Short-term: Independent: Upon 24 hours of
clearance related to to maintain clear appropriate nursing
“Hindi nya mailabas intermittent asthma airway as evidenced by After an hour of - Encourage the use of interventions the
yung ubo nya” as with exacerbation productive cough, appropriate nursing diaphragmatic following goals has met
verbalized by the maintain normal interventions, the client breathing and coughing completely:
mother of the client” respiratory function as will demonstrate techniques.
evidenced by effective technique to Helps to improve The client
Objectives: respiratory rate of maintain airway ventilation and demonstrated
within 12-20cpm, clearance such as mobilize secretions. directed/controlled
Irritable absence of deep huffing and directed coughing.
Non-productive cough shallow breathing and coughing. -Instruct the client in
Deep, shallow absence of tripod directed/controlled The clients was able to
breathing (respiratory position when Long-term: coughing. (e.g., take a maintain clear airway
rate of 28 cpm) breathing after 24 hours deep breath, hold for 2 by having a productive
Tripod position. of nursing After 8 hours of seconds, and cough two cough
interventions. appropriate nursing or three times in
*positive barrel chest interventions, the client succession).
will be able to maintain The most convenient
Vital signs takes as productive cough. way to remove most
follows : secretions is coughing.
BP: 118/77 So it is necessary to
T-38.2 C assist the patient
RR-28 during this activity.
PR: 128 bpm
- Adequately hydrate
the client
Keeps secretions moist
and easier to
expectorate.

- Instruct the client to

avoid bronchial irritants
such as cigarette
smoke, aerosols, and
fumes.
These irritants cause
bronchoconstriction
and increase mucus
production.

-Maintain humidified
oxygen
Increasing humidity of
inspired air will reduce
thickness of secretions
and aid their removal.

Dependent:

-Administer
expectorants as
prescribed.
To dilate the airways

Collaborative:
1. Refer to the
pulmonary
clinical nurse
specialist, home
health nurse, or
respiratory
therapist as
indicated.
-Consultants may be
helpful in ensuring that
 proper treatments are
met.

Darny Kristel Padolina

Outcome
Assessment Diagnosis Planning Intervention Evaluation
Identification
 After all the nursing
Subjective: Increased cardiac interventions, the client Short Term: Independent: Short Term:
“Madalas parang output related to 1. Determine vital After 4 hours of nursing
will: interventions, the client the
nahihirapan ang anak intermittent asthma as After 4 hours of signs/hemodynamic client display
ko huminga kahit evidenced by - Report/demonstrate nursing interventions, parameters including hemodynamic stability and
bagya pa lamang ang tachycardia . the client will display
decreased episodes cognitive status. Note demonstrate an increase in
kanyang nalalakad.” as hemodynamic stability activity tolerance. Goal was
of dyspnea, angina, (e.g., blood pressure, vital signs response to
verbalized by the met.
and dysrhythmias cardiac output within activity/procedures and
mother of the client.
- Display normal range) and Long Term:
time required to return
After 8 hours of nursing
Objective: hemodynamic demonstrate an increase to baseline. interventions, the client is
-pallor stability (e.g., blood in activity tolerance. -. Provides baseline for able to display reduced
-prolonged capillary pressure, cardiac comparison to follow tension, relaxed manner,
refill trends and evaluate ease of movement.
output within Long Term:
-increased cardiac response to interventions.
output index normal range,
adequate urinary - After 8 hours of
-restlessness
output, decreased nursing 2. Review signs of
frequency /absence interventions, the impending
Vital signs takes as client will Display failure/shock, noting
follows: of dysrhythmias).
- Maintain adequate hemodynamic decreased cognition
BP: 118/77 and unstable/low blood
cardiac output of stability (e.g., blood
T-38.2 C
60-100 bpm. pressure, cardiac pressure/invasive
RR-28
output within hemodynamic
PR: 128 bpm
normal range). parameters; tachypnea;
labored respirations;
changes in breath
sounds (e.g., murmurs,
dysrhythmias); and
reduced urinary output.
- Early detection of
changes in these
parameters promote timely
intervention to limit degree
of cardiac dysfunction).

3. Note presence of
pulsus paradoxus,
especially in the
presence of distant
heart sound
- It suggests cardiac
tamponade

4. Keep client on bed or

chair rest in position of
comfort.
- Decreases oxygen
consumption and risk of
decompensation.

5. Note skin color,

temperature, and
moisture.
- Cold, clammy, and pale
skin is secondary to
compensatory increase in
sympathetic nervous system
stimulation and low
cardiac output and oxygen
desaturation.

6. Check for peripheral

pulses, including
capillary refill.
- Weak pulses are present
in reduced stroke volume
and cardiac output.
Capillary refill is
sometimes slow or absent.

7. Assess patient for

understanding and
compliance with
medical regimen,
including medications,
activity level, and diet.
- This promotes
cooperation of patient in
his or her own medical
situation.

Dependent:
8. Administer high-
flow oxygen via mask
or ventilator, as
indicated by the
physician.
- To increase oxygen
available for cardiac
function/tissue perfusion.

9. Administer
 blood/fluid
replacement,
antibiotics, diuretics,
inotropic drugs,
antidysrhythmics,
steroids, vasopressors,
and/or dilators, as
indicated.
- Evaluate response to
determine therapeutic,
adverse, or toxic effects of
therapy.

Chelsea Ellace D. Robles