DX: Ineffective airway clearance R/T airway spasm secondary to asthma As Evidenced by: Adventitious Lung Sound (rhonchi).

Assessment Planning Intervention Rationale Evaluation

Subjective Cue(s): Client At the End of my 8 Hour Establish Rapport to my To ensure client At the End of my 8
verbalized: duty there will be Client cooperation. hour Duty the Goal of
manifestations of having improved
wala naman ko galisud og improved airway clearance airway clearance and
ginhawa pag abut nako dire and no development of Perform and or assist To loosen secretions and no development of
pero naa koy ubo pero wala complications as nebulization PRN. for education of how to complications are
ko gi sip-on dile pd ko evidenced by: perform it correctly. partially met:
hangakon ra As evidenced by:
No Asthma attack(s) Assist in Proper To enhance gas
Objective Cues: Noted. positioning (semi exchange in the lungs. No Asthma attacks
fowlers) noted.
Adventitious breath
Clear breath sounds
sound on lungs upon Hydration helps loosed
loss or decrease of
auscultation(rhonchi). Encourage Client to secretions. Adventitious breath
adventitious breath
increase fluid intake 5-6 sound is still audible
No use of accessory sound volume
glasses a day. (rhonchi).
muscles when (rhonchi)
breathing
Loosened For baseline data.
No complains of chest secretions. Monitor breath sounds, Loosened secretions.
pain. respiratory rate and
other vital signs.
Vital Signs: Ability to
expectorate
3/6/17 8Am secretions.
Health teaching about Client is still
Temp: 37oC
the proper way of practicing how to
PR: 125 Normal overall Vital
coughing. expectorate or cough
RR: 25 signs. out secretions.

Normal Range: Vital signs are all

HR 80-160 Normal.
RR 30-60
Temp 36.5-37.5 3/7/17 12pm
Temp: 36.2oC
PR: 105
RR: 26
 Anatomy and Physiology

Asthma is a common long term inflammatory disease of the airways of the lungs. It is
characterized by variable and recurring symptoms, reversible airflow obstruction, and
bronchospasm. Symptoms include episodes of wheezing, coughing, chest tightness,
and shortness of breath.

Asthma exacerbations consist of acute or subacute episodes of progressively

worsening shortness of breath, coughing, wheezing, and chest tightness or any
combination thereof.