Вы находитесь на странице: 1из 4

Ineffective Bronchial asthma is After 2 days of Independent: • Some degree of

airway a chronic nursing • Auscultate breath bronchospasm


clearance inflammatory interventions, sounds. Note is present with
related to disease of the the patient will adventitious obstructions in
increased airways, associated demonstrate breath sounds airway and may
production of with recurrent, behaviors to like wheezes, or may not be
secretions. reversible airway improve airway crackles and manifested in
obstruction with clearance. rhonchi. adventitious
intermittent • Elevate head of breath sounds.
episodes of the bed, have • Elevation of the
wheezing and patient lean on bed facilitates
dyspnea. Bronchial overbed table or respiratory
hypersensitivity is sit on edge of the function by use
caused by various bed. of gravity.
stimuli, which • Keep • Precipitators of
innervate the vagus environmental allergic type of
nerve and beta pollution to a respiratory
adrenergic receptor minimum like reactions that
cells of the airways, dust, smoke and can trigger or
leading to bronchial feather pillows, exacerbate
smooth muscle according to onset of acute
constriction, individual episode.
hypersecretion of situation. • Provides patient
mucus, and • Encourage or with some
mucosal edema. assist with means to cope
abdominal or with or control
pursed lip dyspnea and
breathing reduce air
exercises. tapping.
• Assist with • Coughing is
measures to most effective
improve in an upright
effectiveness of position after
cough effort. chest
percussion.
• Increased fluid • Hydration helps
intake to 3000 ml/ decrease the
day. Provide viscosity of
warm or tepid secretions,
liquids. facilitating
expectoration.
Collaborative: Using warm
• Administer liquids may
bronchodilators decrease
as prescribed bronchospasm.
• To reduce the
viscosity of
secretions.
Subjective: Decrease tissue SHORT TERM Independent:
perfusion resulting
Patient verbalized; Ineffective Tissue in the failure to After 8 hours of
“Naabat gad ako Perfusion nourish the tissues nursing
nga bagat interventions, client 1. Assess for signs
at the capillary
maghagkot tak mga r/t will: of decreased tissue
level.  Provides
kamot ngan ti-il.” perfusion.
alveolar collapse baseline data.
Reduced arterial (e.g., cold clammy
blood flow causes a. verbalize skin, cyanotic nail
decreased knowledge of bed, lethargic, poor
nutrition and treatment peripheral
Objectives: oxygenation at the regimen,
pulsation,etc)
cellular level. including
Management is medication/s and
directed at their actions and
 Signals severe
• RR:25cpm removing possible side 2. Note declining acidotic state
• cold clammy skin vasoconstricting effects
level of awareness which requires
• cyanotic nail b. demonstrate
factor(s), or consciousness. immediate
beds adequate tissue
improving attention.
• nasal flaring perfusion as
peripheral blood evidenced by:
• lethargic flow, and reducing •
• dyspnea normal RR (12-20 3. Monitor heart  Dysrhythmias
metabolic cpm)
• poor peripheral rate/rhythm. that may occur
demands on the • warm, dry skin
pulsation are due to
body. Decreased • normal capilliary
• dysrrhythmia hypoxia and
tissue perfusion refill electrolyte
can be transient • (-) respiratory imbalances.
with few or difficulty (e.g., nasal
minimal flaring, dyspnea)  Pallor, cool
consequences to • (-) lethargy clammy skin are
the health of the Palpable adequate late changes are
patient. If the peripheral pulses associated with
4. Note skin color, severe of
decreased
temperature and advancing
perfusion is acute moisture. hypoxemia.
and protracted, it
can have  Promotes
devastating participation and
effects on the therapeutic
patient. regimen and
Diminished tissue may reduce
recurrence of
perfusion, which is 5. Discuss cause of disorder.
chronic in nature, chronic condition
invariably results and appropriate
in tissue or organ interventions or  Prevents
damage or death. self-care activities. hypoxemia and
This care plan its use prevents
focuses on the
problems in consequences of
hospitalized longstanding
patients. hypoxemia. This
( source:http://ww saturates
w1.us.elsevierheal circulating
COLLABORATIVE hemoglobin and
th.com/MERLIN/Gu
increases the
lanick/Constructor/ 1. Administer effectiveness of
index.cfm? oxygen as blood that is
plan=55) indicated, using reaching the
appropriate delivery ischemic tissues.
means.