nursinG cAre PLAn 28-1

PATienT WiTH AsTHMA

nurSing DiagnoSiS patient goalS ineffective airway clearance related to bronchospasm, excessive mucus production, tenacious secretions and fatigue as evidenced by ineffective cough, inability to raise secretions, adventitious breath sounds. Maintains clear airway with removal of excessive secretions Experiences normal breath sounds and respiratory rate

expected patient outcomes

respiratory status: Airway Patency Respiratory rate Respiratory rhythm Moves sputum out of airway Ease of breathing Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised Adventitious breath sounds Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None

nursing interventions and Rationales

Asthma Management Determine baseline respiratory status to use as a comparison point. Monitor rate, rhythm, depth and effort of respiration to determine need for intervention and evaluate effectiveness of interventions. Observe chest movement, including symmetry, use of accessory muscles and supraclavicular and intercostal muscle retractions to evaluate respiratory status. Auscultate breath sounds, noting areas of decreased/absent ventilation and adventitious sounds to evaluate respiratory status. Administer medication as appropriate and/or per policy and procedural guidelines to improve respiratory function. Coach in breathing/relaxation techniques to improve respiratory rhythm and rate. Offer warm fluids to drink to liquefy secretions and promote bronchodilation.

nursinG cAre PLAn 28-1

PATienT WiTH AsTHMAcontd

nurSing DiagnoSiS patient goalS Anxiety related to difficulty breathing, perceived or actual loss of control and fear of suffocation as evidenced by restlessness, elevated pulse, respiratory rate and blood pressure. Reports decreased anxiety with increased control of respirations Experiences vital signs within normal limits

expected patient outcomes

Anxiety Level Restlessness Increased blood pressure Increased pulse rate Increased respiratory rate Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None nurSing DiagnoSiS patient goalS

nursing interventions and Rationales

Anxiety reduction Identify when level of anxiety changes to determine possible precipitating factors. Use calm, reassuring approach to provide reassurance. Stay with patient to promote safety and reduce fear. Encourage verbalisation of feelings, perceptions, and fears to identify problem areas so appropriate planning can take place. Instruct patient in the use of relaxation techniques to relieve tension and to promote ease of respirations.

deficient knowledge related to lack of information and education about asthma and its treatment as evidenced by frequent questioning regarding all aspects of long-term management. Describes the disease process and treatment regimen Demonstrates correct administration of aerosol medications Expresses confidence in ability for long-term management of asthma

expected patient outcomes

Asthma self-Management Describes causal factors Initiates action to avoid and manage personal triggers Uses diary to monitor symptoms over time Monitors peak flow routinely Monitors peak flow when symptoms occur Makes appropriate medication choices Demonstrates appropriate use of inhalers, spacers and nebulisers Seeks early treatment of infections Self-manages exacerbations Reports uncontrolled symptoms to healthcare provider Reports asthma controlled Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated
*See Tables 28-9 and 28-13 and Fig 28-6.

nursing interventions and Rationales

Asthma Management Determine patient/family understanding of disease and management to assess learning needs Teach patient to identify and avoid triggers as much as possible to prevent asthma attacks. Encourage verbalisation of feelings about diagnosis, treatment and impact on lifestyle to offer support and increase compliance with treatment. Educate patient about the use of the peak expiratory flow rate (PEFR) meter at home to promote self-management of symptoms. Instruct patient/family on anti-inflammatory and bronchodilator medications and their appropriate use to promote understanding of effects. Teach proper techniques for using medication and equipment (e.g. inhaler, nebuliser, peak flow meter)* to promote self-care. Establish a written plan with the patient for managing exacerbations to plan adequate treatment of future exacerbations.