CUES Subjective Nahihirapa n ako huminga as verbalized by the Pt. Objective V/S taken as follows: T= 37.

.10C P=80 RR= 24cpm BP=130/90

Nsg. Diagnosi s Ineffective airway clearance related to increased productio n of secretions .

Nsg. Background Bronchial asthma is a chronic inflammatory disease of the airways, associated with recurrent, reversible airway obstruction with intermittent episodes of wheezing and dyspnea. Bronchial hypersensitivity is caused by various stimuli, which innervate the vagus nerve and beta adrenergic receptor cells of the airways, leading to bronchial smooth muscle constriction, hypersecretion of mucus, and mucosal edema

Goals/ Objectives Within my 8 hrs. span of care, the patient will:

Nsg. Interventions Establish rapport. Monitor VS Auscultate breath sounds. Note adventitious breath sounds like wheezes, crackles. Elevate head of the bed, have patient lean on over bed table or sit on edge of the bed. Keep environmental pollution to a minimum like dust, smoke and feather pillows, according to individual situation. Encourage or assist with abdominal or pursed lip breathing exercises. Observe for signs of respiratory distress(increase rate,restlessness/ anxiety,use of accessory muscles for breathing). Assist with measures to improve effectiveness of cough effort. Evaluate change in sleep pattern,

Rationales To gain trust and cooperation. To have baseline data. Some degree of bronchospasm is present with obstructions in airway and may or may not be manifested in adventitious breath sounds. Elevation of the bed facilitates respiratory function by use of gravity. Precipitators of allergic type of respiratory reactions that can trigger or exacerbate onset of acute episode. Provides patient with some means to cope To assess changes,note complications.

Evaluation

GOAL MET At the end of my 8hrs span of care, the patient was able to: Demonstrate d behaviors to improve airway clearance.

Demonstrate
behaviors to improve airway clearance.

Abnormal
breath sounds. (wheezing, crackles, noted) Use of accessory muscle. Absent cough. Restlessness

To maintain RR within its normal limits.

RR

decreased from 27 cpm irregular to 20 cpm with regular rhythms.

Coughing is most effective in an upright position after chest percussion. To assess changes,note complications. To mobilize secretions .

noting insomnia or daytime somnolence. Give bronchodilators as ordered. Encourage opportunity to rest.

To promote wellness.

CUES Subjecti ve di ako makatulo g ng maayos sa gabi

Nsg. Diagnosis Objective VS taken as follows: T= 37.10C P=80 RR= 24cpm BP=130/9 0 Sleep Pattern disturbance related to depression secondary to separation from significant others & life change.

Nsg. Background .

Goals/Objectives Within my 8hrs span of care the pt. will be able to: Verbalize understanding of sleep disturbance.

Nsg. Interventions Established rapport Monitor VS Review psychological assessment, noting individual & personality characteristic. Listen to subjective report of sleep quality. Indentify circumstances that interrupt sleep and frequency. Assessed client to develop individual program of relaxation eg.

Rationales To gain trust & cooperation. To gather baseline data. To indentify causative/ contributing factors. To evaluate sleep pattern. To evaluate sleep pattern & dysfunction. To promote wellness.

Evaluation GOAL MET At the end of my 8hrs span of care the pt. was able to; Verbalized understanding of sleep disturbance.

To aid in stress control/ release of energy.

Progressive muscle relaxation. Encourage participation in regular exercise program during day.