Possible Etiologies: (Related to) Bronchospasm Increased production of secretions; retained secretions; thick, viscous secretions ecreased energ!" fatigue • •
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efining characteristic characteristics: s: (Evidenced b!) #tatement of difficult! in breathing $eeling of chest constriction %hanges in depth" rate of respiration; tach!pnea &ach!cardia 'se of accessor! muscles or marked respirator! effort bnormal breath sound, inspirator! and epirator! *hee+ing %ough (persistent), *ithout sputum
Objectives
Goals/ Objectives: Sort ter! goal: %lient *ill demonstra demonstrate te signs of patent air*a! and adeuate o!gen echange *ithin - da!s. "ong ter! goal: %lient *ill demonstra demonstrate te behaviours behaviou rs to improve or maintain air*a! clearance and identif! potential complications complications
and initiate appropriate actions.
Nursing Interventions
Nursing Actions
/. ss ssess ess re resp spira irator tor! ! sta status tus ever! hour during acute
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production Prolonged epiration
Rationale
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phase: lung lung sounds, respirator! rate and depth, presence and and severit! o off *hee+ing, breathing pattern, use of accessor! muscles. ss ssist ist p pati atient ent tto o ass assum umee to comfortablee position, i.e. comfortabl elevate head of bed, have client lean on over bed table or sit on the edge of bed. 1ee 1eep p envi environ ronme menta ntall pollution to a minimum according to individual situation. Enc Encou ourag ragee and and as assis sistt abdominal and pursed 3 lip breathing eercises. eercises. Inc Increa rease se fl fluid uid intak intakee to -555ml" da! *ithin cardiac tolerance. Pro Provid videe *arm *arm li liu uids ids aand nd recommend intake of fluids bet*een meals, meals, instead o off during meals. dm dmini iniste sterr medi medicat cation ionss as indicated. 9o 9onit nitor or sside ide eeff ffect ectss of bronchodilator bronchod ilator (tremors" tach!cardia). Pro Provid videe suppl supplem ement ental al humidification, humidifica tion, e.g., neutrali+er in respirator!
/. #ome #ome degr degree ee in bronchospasm bronchosp asm is presen presentt *ith obstruction in
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Evaluation
Outco!e Criteria: %lient *ill verbali+e reduction or absence in difficult! in breathing and and feeling of chest constriction, respiration and cardiac rate
air*a! and ma! be manifested *ith *hee+ing or absent breath sounds sounds in severe asthma. &ach!pnea is usuall! present to some degree and respirator! d!sfunction is variable depending on underl!ing process such such as allergic allergic reaction. *ithin normal range, absence or Ele Elevat vation ion of head head of the the bed facilitates facilitates respirator! reduction of function b! use of inspirator! and gravit!, ho*ever client in epirator! distress ma! seek *hee+ing, and position that most most eases abilit! to resume breathing. to activities. Precip Precipita itator torss of alle allerg rgic ic %lient *ill be t!pe of respirator! reactions that can trigger able to identif! or eacerbate onset of and avoid acute episode. potential Provid Provides es ssom omee mean meanss to allergens or cope *ith or control stimuli that *ould d!spnea and reduce air trigger asthma trapping. !dra !dratio tion nh help elpss th thin in attack and be able secretions, facilitating to handle epectoration and using s!mptoms if *arm liuids ma! recurrence comes, decrease bronchospasm.
6. $lu $luids ids duri during ng m meal ealss can can increase gastric distension and pressure on the diaphragm. 7. ntic nticho holin linerg ergic ic
prompt follo* up checkup and to al*a!s bring or have the
medicationss are the first prescribed medication line drugs for clients *ith medication"s on hand in case this condition. 8. umidi umidit! t! h help elpss red reduce uce asthma occurs. viscosit! of secretions, facilitating epectorat epectoration ion and ma!. . Breath Breathing ing e eerc ercise isess help enhance diffusion, nebuli+er medications can reduce bronchospasm bronchosp asm and stimulate epector epectoration. ation. /5. Establishes baseline for monitoring progression" regression of disease process.