Question

Asthma. Nursing Diagnosis Nursing Diagnosis Interventions Interventions Positive Outcomes Positive Outeomes Negative Outcomes Negative Outcomes Evaluation Evaluation

Answer 1

Nursing diagnosis and intervention :-

1. Ineffective airway clearance related to airway spasm, secretion retention, amount of mucus.

Goal: The patient showed the ability to maintain the cleanliness of the airway, with the expected outcomes:

There is no secret

Lungs clear sound

Intervention:

1. Airway menagement:

Free the airway (suction)

Monitor the chest wall retraction

Monitor respiration rate

Give a semi-Fowler position

2. Clear the airway:

Listen to lung sounds

Encourage the patient to drink warm

Do suction

Monitor oxygen delivery

Evaluation of lung sounds after suction

2. Ineffective breathing pattern related to spasm of the airway, respiratory muscle fatigue.

Goal: Adequate patient's respiratory status, with the result criteria:

Respiration rate is within normal limits

Not seen the use of additional respiratory muscles

No complaints of pain in breathing

Intervention:

1. Airway management:

Monitor respiratory patients

Monitor the use of additional respiratory muscles (chest wall retraction)

Monitor Vitas signs; respiration, pulse, blood pressure, temperature

Position the patient in semi-Fowler position

2. Oxygen Therapy:

Provide oxygen according to program

Give oxygen through a nasal or face mask canul

The flow of 1-6 liters / minute oxygen concentration produces 24-44%

The flow of 5-8 liters / minute oxygen concentration produces 40-60%

The flow of 8-12 liters / min oxygen concentration produces 60-80%

The flow of 8-12 liters / min oxygen concentration producing 90%

3. Collaboration for bronchodilator therapy.

3.Impaired gas exchange related to bronchospasme, damage to the alveoli.

Goal: effective gas exchange, with expected outcomes:

Free from symptoms of respiratory failure, cianosis, nostril breath

Blood gas analysis results within normal limits.

Intervention:

1. Airway management:

Position the patient in a position semifowler

Auscultation of breath sounds of patients

Patient's fluid balance

Monitor respiration rate

Clear the airway of secretions (Suction)

Teach the client to use an inhaler

2. Acid-base management:

Monitor blood gas analysis

Monitor electrolyte levels

Monitor oxygen saturation

Collaboration of medication to maintain the acid-base balance (sodium bicarbonate)

Monitor hemodynamic status

4. Activity intolerance related to imbalance of oxygen supplied to the needs

Goal: The patient showed tolerant state of activity, with the expected outcomes:

No shortness of breath on exertion

Able to move up

Intervention:

1. Energy management:

Determine the causes of fatigue

Monitor respiratory (respiration, dyspnoea, pallor)

Help clients choose the activities that can be done

Recommended to increase the intake of nutrients

2. Monitor response of breathing during activity, assess abnormal response in respiration, blood pressure, pulse.

5. Knowledge deficit: about asthma, related to lack of information sources.

Goal: increase patient knowledge about asthma, the expected outcomes:

Knowing trigger asthma

Knowing about the things that need to be avoided

Knowing the handling of the attack.

Intervention:

1. Assess the things that have been known to patients

2. Assess the patient's condition before health education, do not provide health education, while patients in the state of attack.

3. Education:

Explain the meaning of asthma

Explain the trigger factor

Describe the things that need to be avoided: elergan factors, stress, excessive cold weather activity

Explain how the handler during an asthma attack at home

Evaluate what has been delivered.

6. Anxiety related to crisis situations: changes in health status

Goal: The patient can control anxiety and increase coping, with expected outcomes:

Patient's expression relaxed

Vital signs are within normal limits

Intervention:

1. Lower levels of anxiety:

Listen to their patients

Explain each will perform maintenance procedures

Instruct the patient to accompany the family as a support system during an asthma attack.

Provide emotional and psychological support

#. Positive outcomes :-

- patient is able to maintain airway

- decreased anxiety level

- normal breathing pattern

- normal gas exchange

#. Evaluation :-

- Patient is maintaining an effective airway with normal vitals and ABG values .