Fundamentals of Nursing Lecture

FINAL REQUIREMENT:

GROUP NO. 6

Group Members:

Cunanan, Stephen Josh J.

Fernando, Nashleen Ysabel M.

Goda, Jamella Charmaine C.

Gribador, Jayne Feline J.

Hernandez, Nicole Jasmiel D.

Jalandoni, Mica Alfonzo A.

Lazo, Arrianne Ashley J.

Lubos, Ella Marie C.

Osmil, Shiney Jane E.

Submitted to:

Clinical Instructor: Ma’am Lizcir T. Panelo

Date: May 2023

 NAME: Ms. B AGE: 30 years old GENDER: Female

Chief complaint: Difficulty in breathing

Medical Diagnosis: Bronchial Asthma

Nursing Diagnosis: Impaired Gas Exchange related to respiratory distress and decreased oxygenation secondary due to acute
exacerbation of asthma

Short-Term Goal: The patient continued to have a clear airway. By having a 95 to 100 percent oxygen saturation.

Long-Term Goal: The nurse observed pale skin that felt chilly to the touch. The patient also made wheezing sounds when exhaling
and slightly gasped for air, relief from the tripod position, and persistent yellowish cough.

ASSESSMENT Nursing Problem Scientific Rationale Intervention Rationale Evaluation

SUBJECTIVE: Ineffective airway Dyspnea - The - Utilized a nasal - Used a nasal Short-Term
“Nahihirapan akong clearance is related medical term for cannula to cannula to increase Evaluation: The
huminga ilang araw to increased shortness of breath or administer 02 oxygen saturation patient continued to
na” as verbalized by excessive trouble breathing. It is inhalation at 2-3 without causing have a clear airway.
the patient secretions of a sign of numerous L/min. discomfort or drying By having a 95 to
mucous as illnesses that have an - Paracetamol was out the nasal 100 percent oxygen
OBJECTIVE: evidenced by impact on the given to control passages. saturation.
- Blood pressure abnormal breathing respiratory system. the fever. - Paracetamol is
of 90/60 sounds. - An elevated bed frequently used to Long-Term Goal:
- Temperature of Bronchial Asthma - head treat fever The nurse observed
38.2C A chronic inflammatory - Used a nasal - An elevated bed pale skin that felt
- Respiratory illness of the airways cannula to head can ease the chilly. The patient
rate of 25 known as bronchial administer extra difficulty in also made wheezing
breaths per asthma is oxygen at a rate breathing by sounds when
minute characterized by of 3 L/min to keep reducing pressure exhaling and slightly
- Pulse rate of bronchial the oxygen on the diaphragm gasped for air, relief
105 beats per hyperreactivity and saturation level - Teaching can help from the tripod
 minute varying degrees of above 92% patients manage position, and
- Patient used airway blockage. - Taught patients their asthma and persistent yellowish
accessory how to manage improve their cough.
muscle while their asthma, quality of life.
breathing-purs prevent
ed lip breathing infections, and
(signs of take their
asthma) medications as
- The patients prescribed.
pale skin is
hard to touch
- The wheezing
sound was
auscultated
- Patient exhibits
coughing with
tenacious
yellowish
phlegm