Assessment

Nursing diagnosis

Scientific Explanatio n exposure to triggers the bronchi (large airways) contract into spasm Inflammati on narrowing of the airways excessive mucus production coughing breathing difficulties

Planning

Nursing Intervention Establish rapport to patient and SO. Auscultate chest, noting presence/chara cter of breath sounds, presence of secretions. Note rate and depth of respirations Review Laboratory data. Administer O2 indicated for underlying pulmonary condition Elevate HOB as appropriate. Maintain a calm attitude while dealing with client and SO.

Rationale To gain trust and have a better NPI. To identify etiology/ precipitati ng factors.

Evaluation

Subjective Data: medyo nahihirapan akong huminga Objective data: Looks pale Restlessn ess Fatigue Use accessory muscles when breathing (+) wheezes With productive cough On high back rest Profound breathing pattern Vital

Ineffective breathing pattern related to bronchosp asm 2 BAiAE

Short term: After 3-4 hrs of effective nursing intervention the patient will established a normaleffective respiratory pattern AEB: (-) Restlessness (-)fatigue (-)Use accessory muscles when breathing With productive cough On moderate high back rest Regular breathing pattern Vital signs: T-36 P-78 R-2224 BP-100/60mmHg

To provide relief .

To promote physiologic/ psychologic ease of maximal inspiration To limit level of

Short term: Goal met as evidenced by: (-) Restlessnes s (-)fatigue (-)Use accessory muscles when breathing With productive cough On moderate high back rest Regular breathing pattern Vital signs: T-36 P-78 R23 BP100/60mmHg Long term

signs: T-36 P-78 R28 BP100/60mmHg

Long term: During the whole duration of hospitalization the patient can/will: Verbalize awareness of causative factors. Initiate needed lifestyle changes Demonstra te appropriate coping behaviors. Maintained normal/sta ble Vital signs Experience d free from signs of hypoxia.

Assist client in the use of relaxation technique. Assist and demonstrate deep breathing and coughing exercise. Encourage position of comfort. Reposition every 2 hrs. . Health teachings: Review etiology and possible coping behaviors Teach conscious control of RR as appropriate. Recommend energy conservation techniques

anxiety.

To assist client in taking control of the situation .

Goal met as evidenced by: able to Verbali ze awaren ess of causati ve factors. Initiate neede d lifestyl e change s Demon strate approp riate coping behavi ors. Maintai ned normal /stable Vital signs Experi enced free

and pacing of activities. Encouraged adequate rest periods between activities Collaborative: Nebuliz ation as ordered Admini ster hydroc ortison e as ordered .

To limit fatigue.

from cyanos is and other signs of hypoxi a.

> To decreased secretions and allow ease from maximal inspiration

Assessment Subjective Data: medyo nahihirapan akong huminga Objective data: Looks pale Restlessnes s Fatigue Use accessory muscles when breathing (+) wheezes With productive cough On high back rest Profound breathing pattern Vital signs: T-36 P-78 R28 BP100/60mmHg

Nursing diagnosis Ineffective breathing pattern related to bronchospasm 2 BAiAE

Planning Short term: After 3-4 hrs of effective nursing intervention the patient will established a normal-effective respiratory pattern AEB: (-) Restlessness (-)fatigue (-)Use accessory muscles when breathing With productive cough On moderate high back rest Regular breathing pattern Vital signs: T-36 P-78 R-22-24 BP-100/60mmHg Long term: During the whole duration of hospitalization the patient can/will: Verbalize awareness of

Nursing Intervention Establish rapport to patient and SO. Auscultate chest, noting presence/character of breath sounds, presence of secretions. Note rate and depth of respirations Review Laboratory data. Administer O2 indicated for underlying pulmonary condition Elevate HOB as appropriate. Maintain a calm attitude while dealing with client and SO. Assist client in the use of relaxation technique. Assist and demonstrate deep breathing and coughing exercise. Encourage position of comfort. Reposition every 2 hrs. . Health teachings: Review etiology and possible coping behaviors

Evaluation Short term: Goal met as evidenced by: (-) Restlessness (-)fatigue (-)Use accessory muscles when breathing With productive cough On moderate high back rest Regular breathing pattern Vital signs: T-36 P-78 R-23 BP-100/60mmHg Long term Goal met as evidenced by: able to Verbalize awareness of causative factors. Initiate needed lifestyle changes Demonstrate appropriate coping

causative factors. Initiate needed lifestyle changes Demonstrate appropriate coping behaviors. Maintained normal/stable Vital signs Experienced free from signs of hypoxia.

Teach conscious control of RR as appropriate. Recommend energy conservation techniques and pacing of activities. Encouraged adequate rest periods between activities Collaborative: Nebulization as ordered Administer hydrocortisone as ordered.

behaviors. Maintained normal/stable Vital signs Experienced free from cyanosis and other signs of hypoxia.