Anda di halaman 1dari 2


Name of Patient: Attending Physician:

Age: Impression/Diagnosis:
Clustered Cues Nursing Diagnosis Rationale Outcome Criteria Interventions Rationale Evaluation
04/20/10 11:00 am INDEPENDENT: 04/20/10 3:00 p.m
Ineffective Airway Bronchospasm and The client will be
Client refrains from Clearance related to bronchoconstriction, able to maintain a 1. Frequently assess Respiratory status GOAL PARTIALLY
talking because he bronchospasm increased mucous patent airway as respiratory status at can change rapidly MET.
finds it hard to secretion and manifested by least every 1 to 2 during an acute The client
breathe while doing airway edema effective hours: respiratory asthma attack and manifested
so. narrow the airways expectoration of rate and depth, its treatment. decreasing
and impair airflow secretions and chest movement or respiratory rate,
Client simply points during acute attack decreasing signs excursion and RR=22
out objects he of asthma. Both and symptoms of breath sounds. breaths/minute and
wants and makes inspiratory and bronchospasm appeared less
signs because he expiratory volume (dyspnea, 2. Monitor skin color Cyanosis, cool strained and
finds it difficult to are affected tachypnea, use of and temperature clammy skin and distressed upon
breath. decreasing the accessory muscles, and level of changes in level of breathing. The
oxygen available at cough) and clearing consciousness. consciousness client was also able
Complains of tight the alveolus for the of breath sounds indicate worsening to cough out
feeling in the chest process of (wheezes) by hypoxia. effective purulent
respiration. 04/20/10 3:00 p.m. 3. Assess arterial sputum
RR=37 Narrowed air blood gas results. These values approximately 60 cc
breaths/minute passages increase ABG Results provide information in amount.
the work of 04/20/10 about gas exchange However, wheezes
With rapid and breathing, HCO3= 23.2 mmol/L and the adequacy of can still be
shallow respirations increasing the O2 Sat= 97.9% alveolar ventilation. auscultated from all
metabolic rate and pH= 7.501 A fall in oxygen lung fields and there
Uses accessory tissue demand for pCO2= 29.8 mmHg saturation levels is is still usage of
muscles to aid in oxygen. Impression: an early indicator of accessory muscles
breathing Respiratory impaired gas and nasal flaring.
PATHOPHYSIOLOGY Alkalosis without exchange.
Exhibits nasal When a trigger such compensation
flaring as inhalation of an
allergen or irritant 4. Assess cough
Faint breath sounds occurs, an acute or effort and sputum Ineffective cough
with expiratory early response for color, may also signal
wheezes (on all lung develops in the consistency and impending
fields) hyperreactive amount. respiratory failure.
airways predisposed
Coughs out purulent to bronchospasm. 5. Place in Fowler’s, These positions
sputum. Sensitized mast High Fowler’s or reduce the work of
cells in the orthopneic (with breathing and
bronchial mucosa head and arms increases lung
release supported on the expansion,
inflammatory overbed table) especially the
mediators such as position to facilitate basilar areas.
histamine, breathing and lung
prostaglandins and expansion.
leukotrienes. These