Rowan College at Burlington County

Associate of Applied Science in Nursing

Nursing Care Plan Form
Student Name: Joseph Welsh Date: 10/20/18
Patient Identifier: EJ Patient Medical Diagnosis: Bronchial Asthma
Nursing Diagnosis: Ineffective Breathing Pattern related to the inflammatory process characteristics by shortness of breath.

a
Assessment Data Goals & Outcome Nursing Interventions Rationale Outcome Evaluation & Re-
(Include at least three-five (Two short term goals and one (List at least two nursing or (Provide reason why Planning

vi
subjective and/or objective long term goal are required for collaborative interventions with intervention is (Was goal met? How would
pieces of data that lead to the each nursing diagnosis. Must rationale for each goal & indicated/therapeutic; provide you revise the plan of care
nursing diagnosis) be patient and/or family outcome.) references.) according tto the patient’s

d
focused; measurable; time- response to current plan ?)

e
specific; and reasonable.)

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Pt winded going to the Short Range Goal #1 1. Assist with use of 1. Maximal respiratory Outcome #1
bathroom. Pt SaO2 greater than 95%. respiratory aids such as efforts reduce potential for Goal was met. Pt had

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on room air during for 30 incentive spirometer. atelectasis and lunch without O2 stayed
Pt O2 stat was below 95% minute periods 2. Assist client in “taking pulmonary infection. above 95% Sa02.

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on room air. control” of respirations as Client may need to be
indicated. Encourage deep reminded and

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Pt was using of accessory Short Range Goal #2 breathing. Focus attention coached to reach specific
muscle Will not using accessory on the steps of breathing. goal. (Doenges,
muscle in breathing in Moorhouse, & Murr, 2014,

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Pt had a wheeze on minute 30 period p. 774) Outcome #2
Auscultate of lungs
co rc 1. Encourage client to use 2. Breathing may no onger
Goal was met. During
lunch Pt did not use
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pursed-lip breathing for be an involuntary activity accessory muscle to
exhalation.(2018) but require conscious breathe
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effort, depending on level

2. Assess the respiratory of injury or involvement
rate, depth, and rhythm. of respiratory muscles.
(2018) (Doenges, Moorhouse, &
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Murr, 2014, p. 252)

Outcome #3
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Goal was not met at time

of sifts changes
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1. Monitor peaked
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expiratory flow rates and

forced expiratory volume
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 as taken by the respiratory 1. Pursed lip breathing
Long Range Goal therapist.(2018) improves breathing patterns
Pt will not need by moving old air out of the
continuous albuterol 2. Maintain head of bed lungs and allowing for new
nebulizer by the end of elevated.(2018) air to enter the lungs.(2018)
shift.
2. Changes in the
respiratory rate and

a
rhythm may indicate an

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early sign of impending
respiratory distress.(2018)

d
1. The severity of the

e
exacerbation can be

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measured objectively by
monitoring these values.

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The peak expiratory flow
rate is the maximum flow

as
rate that can be generated
during a forced expiratory

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maneuver with fully
inflated lungs. It is
measured in liters per

m e
second and requires
co rc maximal effort. When
done with good effort, it
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correlates well with forced
expiratory volume in 1
er res

second (FEV1) measured

by spirometry and
provides a simple,
reproducible measure of
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airway obstruction. (2018)

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2. This promotes maximum

lung expansion and assists
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in breathing. (2018)
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 Reference

1. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2014). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life
Span. Philadelphia, PA: F.A. Davis Company.
2. 7 Asthma Nursing Care Plans • Nurseslabs. (2018, August 17). Retrieved from https://nurseslabs.com/asthma-nursing-care-plans/

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sh
as
w
m e
co rc
o. ou
er res
se dy
ur tus
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This study source was downloaded by 100000791113544 from CourseHero.com on 09-24-2021 08:47:02 GMT -05:00
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