NURSING CARE

bronchial asthma

BY GROUP IV
 CASE

A 34-Year-old woman is being treated with

bronchial asthma. The results off the
assessment : the patient complained of
shortness of breath, productive cough with
thick phlegm, and weakness. Blood pressure
is 110/80 mmHg, pulse rate is 88x/m,
respiratory rate is 26x/m, temperature 37,5
degrees. Pulmonary auscultation results are
wheezing and crackles, oxygen saturation
93%.
 ASSESMENT
1. Clear airway ineffective related to airway spasm
Subjective data :
The patient says cough is accompanied by thick phlegm
The patient loos lethargic

Objective data :
The patient has a productive cough with thick phlegm
Blood pressure : 110/80 mmHg
Temperature 37,5 degres

2. Ineffective breathing pattern related to bronchoconstriction

Subjective data :
Patient says shortness of breath

Objective data :
The patient appears short of breath
Wheezing and bronchial breath sounds
Oxygen saturation : 93%
Respiration : 26x/m pattern related to bronchoconstriction
 NURSING CARE
Nursing Goals and Outcome Nursing RATIONALE
Diagnosa Interventions

After performing 1. Cough exercises 1. To train

Clear airway nursing actions for one effective patients to
ineffective hour, it is expected 2. cough ability have the
related to thet the problem of 3. Therapeutic: adjust the ability to
airway clearing the airway is semi-Fowler`s position, 2. cough
spasm not effectively lost or with a degree of effectively
resolved with the inclination 45 degres 3. To clear
following criteria: 4. Education: Explain the secretions or
1. Main Outcome: purpose and procedur for foreign bodies in
Clear the airway effective coughing the airway
2. Decreased sputum Effective cough : 4. To help clients
production(50 - Take a deep breath 4-5 cough the correct
Effective cough times effective
increased(5) I- n the next breath hold 5. To help the
  for 1-2 seconds patient`s healing
- Lift shoulders and relax process
chest and caugh  
vigorously
5. Collaboration: gift
 the kind of
medicine is
orsiprenalin
(alupent),
fenoterol (
berotec),
terbutalin
(bricasma),
aminofilin(am
icam supp),
teofilin
(amilex)

Ineffective  1. Do not use 1. Teach 1. Help the

bre`athing accessory the clien clien
pattern muscles to diaphragm prolong the
related to breathe atic expiration
bronchoconst 2. breathing time
riction Symmetrical and lip
  left and right breathing
ches
expansion
 
Vital sign Give proper Prolonged
blood pressure: oxygen, using a oxygen
100/80 mmHg nasal cannula, 2 deprivation can
pulse:80x/m liters per lead to hypoxia
respiration:26x minute Control the
/m 3. Client extent of the
temperature: development clients ling
37,5 c observation ekspansi on
oxygen theraphy
saturation: 93% oxygen
THANK YOU . . .