SKIN - warm, slightly dry, hair evenly distributed HEAD -
symmetric skull, no flaking of scalp, no lesions and tenderness
EYES - no redness and discharges, sclera white and clear, pupils
reactive to light and accommodation NOSE AND SINUSES - nasal septum
straight, not perforated, no discharged, NGT present
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THORAX AND LUNGS - thorax is symmetric, chest expansion is
decrease due to muscle weakness, bony prominences are marked, there
is loss of subcutaneous tissue, no tenderness, wheezes audible upon
auscultation UPPER EXTREMITIES - decorticate position, arms are
unable to abduct and adduct NAILS - convex in curvature, rough,
with slightly delayed capillary refill
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III. PATIENT HISTORY
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PATIENT X Known to have asthma and DM RTA Sep. 26,2011 RMH Oct.
5,2011 Ward Oct. 24,2011
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Dec. 7,2011 semi- conscious, unable to speak and follows
command, quadriphlegic, on NGT and diaper Shortness of breath---low
O2 sat.--- tracheostomy tube ( Jan. 12, 2013) VS stable with seldom
episodes of desaturation
STIMULI ( allergen, irritant, virus, cold air, exercise etc.)
Activation of Inflammatory cells Migration into airways and
activation of more inflammatory cells Airway hyperresponsiveness
Airway obstruction Asthma symptoms
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Frequent cough, especially at night Losing your breath easily
or shortness of breath Feeling very tired or weak when exercising
Wheezing or coughing after exercise Feeling tired, easily upset,
grouchy, or moody Decreases or changes in lung function as measured
on a peak flow meter Signs of a cold or allergies (sneezing, runny
nose, cough, nasal congestion, sore throat, and headache) Trouble
sleeping
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Severe wheezing when breathing both in and out Coughing that
won't stop Very rapid breathing Chest pain or pressure Tightened
neck and chest muscles, called retractions Difficulty talking
Feelings of anxiety or panic Pale, sweaty face Blue lips or
fingernails
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Assist him to relax as much as possible. Administer oxygen via
nasal cannula to ease breathing and to increase arterial oxygen
saturation during an acute asthma attack. Adjust oxygen according
to the patients vital functions and ABG measurements. Administer
drugs and I.V. fluids as ordered.
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Decreased ability to exercise and take part in other activities
Lack of sleep due to night time symptoms Permanent changes in the
function of the lungs Persistent cough Trouble breathing that
requires breathing assistance (ventilator) DEATH
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1. Ineffective airway clearance related to mucus accumulation.
2. Impaired Gas Exchange related to altered oxygen supply,
obstruction of airways by secretions, bronchospasm. 3. Ineffective
breathing pattern related to decreased lung expansion. 4.
Hyperthermia related to underlying infection in the lungs. 5.
Impaired nutrition less than body requirements related to
inadequate intake.
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ASSESSMENTNURSING DIAGNOSIS OBJECTIVES NURSING INTERVENTION
RATIONALEEVALUATION Subjective: N/A Objective: -(+)wheezing
-Tachypnia bilateral -(+) secretions characterized by: thick,
greenish in color, approx. amount 5-8cc q suctioning -Frequent
coughing Ineffective Airway Clearance related to accumulation of
mucus. After 12 hrs. of nursing intervention the patient will be
able to expel secretions effectively. After 3-5 days of nursing
intervention the patient will maintain clear airway. 1. Position
with the head of the bed elevated, head aligned properly in
straight position. 2. Change position frequently. 3. Keep patient
environment free from source of allergens, such as dust, powder,
smoke. - Proper positioning facilitate effective passage of air
through the lungs and provide good aeration of lung segments. -
Changing of position aids in mobilization of secretions that may
ease expectoration of secretions. - Precipitators of allergic type
of respiratory reactions that can trigger or exacerbate onset of
acute episode. Goal met. -Patient maintained a patent airway and
demonstrated signs of reduction in respiratory secretions.
-Displayed decreasing amount of secretions.
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4. Provide chestphysiothera py BID for 5 days as indicated by
treatment. 5. Nebulize with pulmicort |+ atrovent every 6 hrs. as
ordered. 6.Administer mucolytics 10 ml x 7 days as ordered CPT
helps in mobilization of secretions - Nebulization may be used to
open constricted airways and liquefy secretions. -Facilitates
liquefaction and removal of secretions
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ASSESSMENTNURSING DIAGNOSIS OBJECTIVES NURSING INTERVENTION
RATIONALEEVALUATION Subjective: NA Objective: -with slightly
delayed capillary refill (4 secs.) -episodes of frequent
desaturation approx. 2-4x/ shift -(+) clubbing of fingernails
Impaired Gas Exchange related to altered oxygen supply, obstruction
of airways by secretion, bronchospasm. After 12 hrs of nursing
intervention the patient will be free from episodes of desaturation
as manifested by oxygen saturation of 95- 100%. After 3-5 days of
nursing intervention the patient will demonstrate improved
ventilation and adequate oxygenation of tissues as evidenced by
normal respiratory rate (20bpm), and good breathing pattern.
1.Provide adequate rest. 2.Keep environment free of allergen.
3.Administer oxygen as ordered. 4. Nebulize the patient as ordered.
5. Administer meds. As ordered -To decrease oxygen demand. -To
prevent irritation of bronchial walls. -To increase oxygen of the
patient. -To promote bronchodilation. -To promote curative aspect
GOAL MET. Patient is free from desaturation episode as manifested
by O2 sat. of 99%.
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ASSESSMENTNURSING DIAGNOSIS OBJECTIVES NURSING INTERVENTION
RATIONALEEVALUATION Subjective: NA Objective: -(+) dyspnea
-shortness of breath -increased work of breathing, use of accessory
muscles -(+) nasal flaring -decrease O2 sat. Ineffective Breathing
Pattern related to airway constriction secondary to bronchial
asthma After 12 hrs. of nursing intervention the patient will
demonstrate breathing in normal rate, depth & rhythm. After 3-5
days of nursing intervention the patient will experience no
cyanosis, dyspnea and normal range O2 saturation. 1. Maintain a
clear airway, suction PRN, CPT as indicated. 2. Elevate the head
and help change the position. 3.Nebulize with pulmicort |+
atrovent, administer mucolytics as ordered 4. Collaboration
-Provide supplemental oxygen -Helps in mobilization of secretions.
-Changing of position aids in mobilization of secretions that may
ease expectoration of secretions. -Nebulization may be used to open
constricted airways & liquefy secretions as well as the
mucolytics. -maximize breath and reduce labor GOAL MET.
Demonstrated normal breathing, no cyanosis and dypnea, and normal
O2 saturation.
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Asthma is a chronic inflammation of the bronchial tubes
(airways) that causes swelling and narrowing (constriction) of the
airways. The bronchial narrowing is usually either totally or at
least partially reversible with treatments. The most common chronic
illness in children, affecting one in every 15. It involves only
the bronchial tubes and usually does not affect the air sacs or the
lung tissue. The narrowing that occurs in asthma is caused by three
major factors: inflammation, bronchospasm, and
hyperreactivity.
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Allergy can play a role in some, but not all, asthma patients.
Many factors can precipitate asthma attacks and they are classified
as either allergens or irritants. Symptoms include shortness of
breath, wheezing, cough, and chest tightness.It is usually
diagnosed based on the presence of wheezing and confirmed with
breathing tests. Chest X-rays are usually normal in asthma
patients. Chest X-rays Avoiding precipitating factors is important
in the management of asthma. Medications can be used to reverse or
prevent bronchospasm in patients with asthma.
