Asthma Nursing Care Plan _NCP_ – Ineffective Airway Clearance

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Nursing Diagnosis

Nursing Diagnosis:  Ineffective Airway Clearance

Possible Etiologies: (Related to) Bronchospasm Increased production of secretions; retained secretions; thick, viscous secretions ecreased energ!" fatigue • •



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 epirator! *hee+ing %ough (persistent), *ithout sputum

Objectives

Goals/ Objectives: Sort ter! goal: %lient *ill demonstra demonstrate te signs of patent air*a! and adeuate o!gen echange *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 epiration

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 eercises. eercises. Inc Increa rease se fl fluid uid intak intakee to -555ml" da! *ithin cardiac tolerance. Pro Provid videe *arm *arm li liu 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 epirator! 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 eacerbate 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 epectoration and using s!mptoms if *arm liuids ma! recurrence comes, decrease bronchospasm.

 

treatments. /5. 9onitor B<s, p pulse ulse oimetr!, chest = ra!.

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 epectorat epectoration ion and ma!. . Breath Breathing ing e eerc ercise isess help enhance diffusion, nebuli+er medications can reduce  bronchospasm  bronchosp asm and stimulate epector epectoration. ation. /5. Establishes baseline for monitoring progression" regression of disease  process.

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