NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE Goal INTERVENTION RATIONALE EVALUATION

Independent:
Subjective: After 3 days of . Some degree of After 3 days of
Ineffective Bronchial asthma is . Auscultate breath bronchospasm
nursing sounds. Note nursing
“Nahihirapan ako airway a chronic is present with
huminga” as interventions, interventions,
clearance inflammatory adventitious obstructions in
the patient will the patient was
verbalized by the demonstrate breath sounds airway and may
patient. related to disease of the
like wheezes, able to
increased airways, associated behaviors to crackles and or may not be
Objective: manifested in demonstrate
production with recurrent, improve airway rhonchi. adventitious behaviors to
of clearance.
. Use of reversible airway
secretions. breath sounds. improve airway
obstruction with
accessory . Elevation of the
intermittent clearance.
muscle. . Elevate head of bed facilitates
episodes of the bed, have
respiratory
wheezing and . patient
Keep lean on
. Abnormal overbed table or function by use
dyspnea. Bronchial of gravity.
breath hypersensitivity is sit on edge of the
bed. . Precipitators of
sounds. caused by various
allergic type of
stimuli, which
respiratory
innervate the vagus environmental
. V/S taken as reactions that
follows: nerve and beta pollution to a can trigger or
minimum like exacerbate
adrenergic receptor
T: 37.3
cells of the airways, dust, smoke and onset of acute
P: 82 leading to bronchial feather pillows, episode.
R: 25 smooth muscle according to
BP: 110/80 constriction, individual . Provides patient
hypersecretion of situation. with some

mucus, and . Encourage or means to cope

assist with with or control
mucosal edema. dyspnea and
abdominal or
pursed lip reduce air
tapping.
breathing
exercises.
 . Coughing is
. Assist with most effective
measures to in an upright
position after
improve chest
effectiveness of percussion.
cough effort.
. Increased fluid . Hydration helps
decrease the
intake to 3000 ml/
day. Provide viscosity of

warm or tepid secretions,

liquids. facilitating
expectoration.
Using warm
liquids may
decrease
bronchospasm.

Collaborative: . To reduce the

. Administer viscosity of
bronchodilators secretions.
as prescribed.