NURSING CARE PLAN: INEFFECTIVE AIRWAY
Name of Patient: Cell Phone
Age: 74 years old
Chief Complaint: Difficulty of Breathing
Diagnosis: Bronchial Asthma, in acute exacerbation t/c CAP
| CUES | NURSING DIAGNOSIS | ANALYSIS/HEALTH IMPLICATION | GOAL AND OBJECTIVES | NURSING INTERVENTIONS | RATIONALE | EVALUATION |
| INTERACTION The client’s relative verbalized “Hinihingal siya” The client verbalized “Nahihirapan ako huminga” OBSERVATION · Difficulty of breathing · Difficulty in vocalizing · Pale and weak · Restlessness · Cough MEASUREMENT Temperature: 37.2° C Respiratory Rate: 16 breaths per minute Blood Pressure: 130/70 mmHg | Ineffective airway clearance related to asthma | IMMEDIATE CAUSE Asthma INTERMEDIATE CAUSE Diffuse airway inflammation ROOT CAUSE Exposure to indoor and outdoor allergens HEALTH IMPLICATION Substances such as hydrocarbons and oxidants emitted by cars and factories interfere with oxygenation by directly damaging the lungs. Carbon monoxide inhibits oxygen attachment onto hemoglobin. Because they are respiratory irritants, pollutants caused increased mucus production and may contribute to bronchitis and asthma. Workers in industrial plants or in certain occupation may be exposed to strong concentrations of specific pollutants and harmful dust. These workers may be prone to development of breathing problems. (Fundamentals of Nursing by Craven and Hirnle, 4th edition page 813) | GOAL After 8 hours of shift, the client will be able to maintain airway clearance and effective gas exchange OBJECTIVES (1) The client will maintain adequate, patent airway (2) Encourage and teach the client the importance of adequate hydration (3) Provide oxygen therapy (4) Respiratory monitoring | a. Position head midline with flexion appropriate for age/condition b. Elevate head of the bed/change position every 2 hours and as necessary a. Increase fluid intake to at least 2000mL/day within level of cardiac tolerance b. Encourage to take several deep breaths c. Encourage to take a deep breath, hold for 2 seconds, and cough two or three times in succession d. Provide supplemental humidification, if needed a. Instruct the client about importance of leaving oxygen delivery device on b. Periodically check oxygen delivery device to ensure that the prescribed concentration is being delivered a. Auscultate breath sounds and assess air movement b. Monitor rate, rhythm, depth, and effort of respirations | Open or maintain open airway in at-rest or compromised individual (Nurse’s Pocket Guide by Doenges, Moorhouse and Geissler-Murr, 9th edition, page 70) To take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage of/ventilation to different lung segments (pulmonary toilet) (Nurse’s Pocket Guide by Doenges, Moorhouse and Geissler-Murr, 9th edition, page 70) Adequate fluid intake enhances liquefaction of pulmonary secretions and facilitates expectoration of mucus (Fundamentals of Nursing by Kozier, 7th edition page 1327) Deep breathing promotes oxygenation before controlled coughing (Fundamentals of Nursing by Kozier, 7th edition page 1327) Controlled coughing is accomplished by closure of the glottis and the explosive expulsion of air from the lungs by the work of abdominal and chest muscles (Fundamentals of Nursing by Kozier, 7th edition page 1327) A variety of respiratory therapy treatments may be used to open constricted airways and liquefy secretions (Fundamentals of Nursing by Kozier, 7th edition page 1328) Oxygen demand is greater during febrile illness and physical stress. At low PO2 level in the atmosphere, oxygen saturation falls rapidly; therefore oxygen should be maintained , especially during activity A variety of respiratory therapy treatments may be used to open constricted airways and liquefy secretions (Fundamentals of Nursing by Kozier, 7th edition page 1328) Too much or too little can be detrimental, especially during activity A variety of respiratory therapy treatments may be used to open constricted airways and liquefy secretions (Fundamentals of Nursing by Kozier, 7th edition page 1328) To ascertain status and note progress (Nurse’s Pocket Guide by Doenges, Moorhouse and Geissler-Murr, 9th edition, page 71) Provide basis for evaluating adequacy of ventilation (Fundamentals of Nursing by Kozier, 7th edition page 1327) | EFFECTIVENESS (1) Was the client maintain adequate, patent airway _yes __no why? (2) Was the client able to promote systemic fluid hydration _yes __no why? (3) Was the client was able to be provided with oxygen therapy? _yes __no why? (4) Was the client able to be monitor regarding to his respiratory functioning? _yes __no why? EFFICIENCY Was the interventions done within the time frame? _yes __no why? APPROPRIATENESS Were the interventions suitable to the client? _yes __no why? ACCESSIBILITY Were the interventions acceptable to the client? _yes __no why? ADEQUACY Were the interventions adequate to meet the client’s needs? _yes __no why? |
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