Patients name: Mr.

M Sex: Male Assessment Nursing Diagnosis Subjective: Ineffective breathing pattern related Objective: to smooth patient is muscle constriction of anxious and the irritable bronchioles. able to speak oriented to time, person and place ambulato ry dry coughing with loud hacks slow and wheezy breathing

NURSING CARE PLAN Inference Exposure to environmental factors such as cold, smoking, and pollutants IgE antibodies are produced as an immune response IgE attaches to the mast cells of the lungs Re-exposure to antigens in the environment results in the antigen binding to the antibody Mast cell products (chemical mediators) are released histamine, bradykinin, prostaglandin Mediators affects smooth muscles causing bronchospasm and mucous membrane swelling Airways are obstructed Passage of O2 and CO2 between the alveoli and vascular system are decreased Planning Goal : After 4 hours of nursing intervention the patient will demonstrate an improved ventilation and adequate oxygenation of tissues and absence of signs of respiratory distress Objectives: Asses causative and contributing factors Evaluate respiratory functions Correct or improve existing deficiencies Promote wellness Nursing Interventions Identify and eliminate the presence of environmental factors Assess respiratory rate and depth and inspect nailbeds and buccal membrane Auscultate breath sounds Ward: Emergency Ward Rationale Evaluation To be able to reduce patients exposure To determine if there is presence of cyanosis To note for adventitious breath sounds as well as fremitus To evaluate cerebral perfusion To asses the severity of patients condition To maintain airway To promote optimal chest expansion To prevent exhaustion To dilate bronchial smooth muscles and facilitate respiration Goal partially met: After 4 hours of nursing intervention the patient was able to demonstrate decreased signs of respiratory distress

Asses level of consciousness and mentality changes Monitor vital signs

Elevate head of bead and position appropriately Encourage deep breathing exercises Encourage rest and limit activities and promote restful environment Administer medications as indicated (corticosteroids, bronchodilators, antibiotics)

Monitor therapeutic and adverse effects of drug therapy (such as increased heart rate) Encourage patient to decrease smoking Demonstrate appropriate nebulization techniques Assessment Subjective: Ayoko, gusto ko nang umuwi.as verbalized by the patient Objective: Patient is anxious and irritable Patient experiences fear Patient is restless and uneasy Vital signs are as follows: T: 37.8 oC PR: 97bpm, RR: 21cpm, BP: 120/90mmHG Able to speak Oriented to time, person and Nursing Diagnosis Moderate anxiety related to fear of being rendered by medical interventions Inference Heightened emotional arousal Elevated physiological response and catecholamine levels Disturbances of the limbic system in the cerebral cortex Underactivation of the serotonergic system and an overactivation of the noradrenergic system Disruption of the gamma-butyric acid (GABA) system Fear of Intravenous administrations of medication Fear of being hospitalized Planning Goal : After 4 hours of nursing intervention the patient will appear relaxed and report anxiety is reduced to a manageable level Objectives: Asses level of anxiety Assist patient to identify feelings and begin to deal with the situation Encourage patient to cooperate in rendering patient care Promote wellness Nursing Interventions Identify the patients perception towards the situation Provide a calm and quiet environment Ask patient to identify and describe his feelings Acknowledge fear or anxiety Explain to the patient the purpose of each medical interventions Administer medications as indicated Monitor therapeutic and adverse effects of drug therapy Render interventions with calm and ease

To prevent the severity of patients condition To eliminate triggering factors To provide proper therapy at home Rationale To determine if the level of anxiety To reduce stimulation provoking anxiety To increase recognition to reality To avoid giving patient false reassurances To help the patient understand and reduce anxiety To alleviate patients condition To prevent the severity of patients condition To provide therapeutic care Evaluation Goal met: After 4 hours of nursing intervention the patient was able to cooperate with the interventions and was able to report anxiety reduced to a manageable level

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Prepared By: PASATIEMPO, Niko Miguel Z.