This nursing care plan is for a patient experiencing an asthma attack. The patient is exhibiting signs of ineffective breathing such as a respiratory rate of 37 breaths per minute, using accessory muscles to breathe, and nasal flaring. The nursing diagnosis is ineffective breathing pattern related to bronchospasm and decreased lung expansion from the asthma attack. Interventions include monitoring vital signs and providing rest periods, positioning the patient in a Fowler's position to facilitate breathing, and teaching breathing techniques to help control the patient's breathing pattern and reduce symptoms. The goal is for the patient to establish an effective respiratory pattern with a stabilized respiratory rate and decreased chest tightness and distress by 3:00 pm.
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Ineffective Breathing Pattern related to bronchospasm, decreased lung expansion
This nursing care plan is for a patient experiencing an asthma attack. The patient is exhibiting signs of ineffective breathing such as a respiratory rate of 37 breaths per minute, using accessory muscles to breathe, and nasal flaring. The nursing diagnosis is ineffective breathing pattern related to bronchospasm and decreased lung expansion from the asthma attack. Interventions include monitoring vital signs and providing rest periods, positioning the patient in a Fowler's position to facilitate breathing, and teaching breathing techniques to help control the patient's breathing pattern and reduce symptoms. The goal is for the patient to establish an effective respiratory pattern with a stabilized respiratory rate and decreased chest tightness and distress by 3:00 pm.
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This nursing care plan is for a patient experiencing an asthma attack. The patient is exhibiting signs of ineffective breathing such as a respiratory rate of 37 breaths per minute, using accessory muscles to breathe, and nasal flaring. The nursing diagnosis is ineffective breathing pattern related to bronchospasm and decreased lung expansion from the asthma attack. Interventions include monitoring vital signs and providing rest periods, positioning the patient in a Fowler's position to facilitate breathing, and teaching breathing techniques to help control the patient's breathing pattern and reduce symptoms. The goal is for the patient to establish an effective respiratory pattern with a stabilized respiratory rate and decreased chest tightness and distress by 3:00 pm.
Copyright:
Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOC, PDF, TXT or read online from Scribd
Age: Impression/Diagnosis: Clustered Cues Nursing Diagnosis Rationale Outcome Criteria Interventions Rationale Evaluation 04/20/10 11:00 am INDEPENDENT: 04/20/10 3:00 p.m Ineffective The physiologic The client will be Client refrains from Breathing Pattern changes in lung able to establish an 1. Frequently assess Early identification GOAL PARTIALLY talking because he related to ventilation that effective respiratory respiratory rate, of ineffective MET. finds it hard to bronchospasm, occur during an pattern so as to pattern, and breath respirations allow The client breathe while doing decreased lung acute asthma provide adequate sounds. Note timely initiation of manifested so. expansion attack impair both ventilation as manifestations of interventions. decreasing lung expansion and manifested by ineffective respiratory rate, Client simply points emptying. Anxiety stabilizing breathing. RR=22 out objects he caused by hypoxia respiratory rate, Tachypnea, breaths/minute and wants and makes and dyspnea decreasing chest 2. Monitor vital tachycardia, an appeared less signs because he compounds the tightness, slight to signs and laboratory elevated blood strained and finds it difficult to problem by no nasal flaring and results. pressure, and distressed upon breath. increasing the decreasing usage of increasing breathing. However, respiratory rate. accessory muscles hypoxemia and wheezes can still be Complains of tight by 04/20/10 3:00 hypercapnia are auscultated from all feeling in the chest PATHOPHYSIOLOGY p.m. signs of lung fields and there When a trigger such compromised is still usage of RR=37 as inhalation of an respiratory status. accessory muscles breaths/minute allergen or irritant 3.Assist with self- and nasal flaring. occurs, an acute or care activities. This conserves With rapid and early response energy and reduces shallow respirations develops in the 4. Provide rest fatigue. hyperreactive periods between Uses accessory airways predisposed scheduled activities Scheduled rest is muscles to aid in to bronchospasm. and treatments. important to breathing Sensitized mast prevent fatigue and cells in the 5. Place in Fowler’s, reduce oxygen Exhibits nasal bronchial mucosa High Fowler’s or demands. . flaring release orthopneic (with inflammatory head and arms These positions ABG Results mediators such as supported on the reduce the work of 04/20/10 histamine, overbed table) breathing and HCO3= 23.2 mmol/L prostaglandins and position to facilitate increases lung O2 Sat= 97.9% leukotrienes. These breathing and lung expansion, pH= 7.501 mediators stimulate expansion. especially the pCO2= 29.8 mmHg parasympathetic basilar areas. Impression: receptors and 6. Teach and assist Respiratory bronchial smooth to use techniques to Alkalosis without muscle to produce control breathing compensation bronchoconstriction. pattern: Pursed- lip They also increase a. Pursed-lip breathing helps capillary breathing keep airways open permeability, b. Abdominal by maintaining leading to mucosal breathing positive pressure, edema, and c. Relaxation and abdominal