NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Independent:
Subjective: Ineffective Bronchial asthma is After 3 days of • Auscultate breath • Some degree of After 3 days of
airway nursing sounds. Note bronchospasm nursing
“Nahihirapan ako clearance a chronic interventions, interventions,
adventitious is present with
huminga” as related to inflammatory the patient will breath sounds obstructions in the patient was
verbalized by the increased disease of the demonstrate like wheezes, airway and may able to
patient. production of airways, associated behaviors to crackles and or may not be demonstrate
secretions. with recurrent, improve airway rhonchi. manifested in behaviors to
Objective: clearance. adventitious improve airway
reversible airway
breath sounds. clearance.
• Use of obstruction with • Elevate head of • Elevation of the
accessory intermittent the bed, have bed facilitates
muscle. episodes of patient lean on respiratory
wheezing and overbed table or function by use
• Abnormal dyspnea. Bronchial sit on edge of the of gravity.
breath bed.
hypersensitivity is
sounds. • Keep • Precipitators of
caused by various environmental allergic type of
• V/S taken as stimuli, which pollution to a respiratory
follows: innervate the vagus minimum like reactions that
nerve and beta dust, smoke and can trigger or
T: 37.3 adrenergic receptor feather pillows, exacerbate
P: 82 according to onset of acute
cells of the airways,
R: 25 individual episode.
BP: 110/80 leading to bronchial situation.
smooth muscle • Encourage or • Provides patient
constriction, assist with with some
hypersecretion of abdominal or means to cope
mucus, and pursed lip with or control
breathing dyspnea and
mucosal edema. exercises. reduce air
tapping.
• Assist with • Coughing is
measures to most effective
improve in an upright
effectiveness of position after
cough effort. chest
percussion.
• Increased fluid • Hydration helps
intake to 3000 ml/ decrease the
day. Provide viscosity of
warm or tepid secretions,
liquids. facilitating
expectoration.
Using warm
liquids may
decrease
bronchospasm.

Collaborative:
• Administer • To reduce the
bronchodilators viscosity of
as prescribed. secretions.