Any infectious organisms that reach the alveoli are likely to be highly

virulent

They may overwhelm the macrophages, resulting in production of a fibrin-

rich exudate that fills the infected and neighbouring alveolar spaces

Causing them to stick together, rendering them airless

The inflammatory response also results in a proliferation of neutrophils.

Leading to fibrosis and pulmonary

oedema, which also impairs lung
Pleural
expansion. Effusion
 Nursing Diagnosis

1. Ineffective airway clearnce related to copious tracheobronchial

secretions.
2. Activity Intolerance related to impaired respiratory function.
3. Risk of Deficient Fluid Volume related to fever and a rapid
respiratory
Nursing Interventions
 Improve airway patency
 Removal of secretions.
 Adequate hydration of 2 to 3 liters per day thins loosens pulmonary secretions.
 Humidification may loosen secretions and improve ventilation.
 Coughing exercises. 
 Chest physiotherapy. 
To promote rest and conserve energy:

 Encourage avoidance of overexertion and possible exacerbation of

symptoms.
 Provide Semi-Fowler’s position. 
 To promote fluid intake

 Fluid intake. Increase in fluid intake to at least 2L per day to replace

insensible fluid losses.
 To maintain nutrition

 Administer fluids with electrolytes. This may help provide fluid,

calories, and electrolytes.
 Give Nutrition-enriched beverages.
Nursing Diagnosis-1
Ineffective Breathing Pattern Related To Swelling and spasm of the bronchial tubes in
response to inhaled irritants, infection, drugs, allergies or infection.

Nursing Interventions

Assess the client’s vital signs as needed while in distress.

Assess the respiratory rate, depth, and rhythm.

Assess the client’s level of anxiety
Assess breath sounds and adventitious sounds such as wheezes
and stridor.
Ineffective Breathing Pattern

Nursing Interventions

Assess the relationship of inspiration to expiration.

Assess for signs of dyspnea (flaring of nostrils, chest retractions, and use of
accessory muscle).

Assess for conversational dyspnea.

Assess for fatigue

Assess the presence of paradoxical pulse of 12 mm Hg or greater.

 Ineffective Breathing Pattern

Nursing Interventions

Monitor oxygen saturation.

Monitor arterial blood gasses (ABG).

Administer mediaction as ordered:
•Short-acting beta-2-adrenergic agonist.Albuterol (Proventil, Ventolin).
•Levalbuterol (Xopenex).
•Terbutaline (Brethine).
 Nursing Diagnosis-2.
Ineffective Airway Clearance Related to Bronchospasms
Nursing Interventions

Assess respiratory rate, depth, and rhythm.

Assess for color changes in the buccal mucosa, lips, and nail beds.

Auscultate lungs for adventitious breath sounds (wheezes and rhonchi).

Assess the effectiveness of cough.

. Monitor oxygen saturation using pulse oximetry.

 Nursing Diagnosis-3
Deficient Knowledge Related to Chronicity of disease

Nursing Interventions
Assess the client’s knowledge of care for status asthmaticus, as appropriate.

Assess past and present therapies, including the client’s response to them.

Assess the client’s knowledge of asthma triggers and asthma medications:

 Treatment for status asthmaticus.
 Correct use of metered-dose inhaler (MDI) and spacer.
 Use of spacers with an MDI.
 Ability to distinguish between rescue medications and controllers.
NURSING DIAGNOSIS

 Ineffective airway clearance related to thick, tenacious mucus production.

 Ineffective breathing pattern related to tracheobronchial obstruction.
 Risk for infection related to bacterial growth medium provided by pulmonary mucus
and impaired body defenses.
 Imbalanced nutrition:less than body requirements related to impaired absorption of
nutrients.
 Anxiety related to hospitalization.
 Compromised family coping related to child’s chronic illness and its demands on
caregivers.
 Deficient knowledge of the caregiver related to illness, treatment, and home care.
NURSING INTERVENTIONS
1. Improve airway clearance. 
 Monitor the child for signs of respiratory distress.
 Teach the child to cough effectively
 Examine and document the mucus produced
 Increase fluid intake; and encourage the child to drink extra fluids.

2. Improve breathing
Maintain the child in a semi-Fowler’s position
Use pulse oximetry; maintain oxygen saturation higher than 90%
Administer oxygen as ordered; administer mouth care every 2 to 4 hours; perform chest
physiotherapy every 2 to 4 hours as ordered
NURSING INTERVENTIONS
 Prevent infection
•   Good handwashing techniques should be practiced by all.
• Practice and teach other good hygiene habits; monitor vital signs every 4
hours.
• Monitor vital signs every 4 hours.

Maintain adequate nutrition.

• Provide the child with high-calorie, high protein snacks, such as peanut butter
and cheese. Administer pancreatic enzymes with all meals and snacks
• Encourage the child to eat salty snacks; report any changes in bowel movements.