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Student Nurse

The patient, a 74-year-old male, presented with difficulty breathing and abnormal breath sounds diagnosed with bronchial asthma in acute exacerbation. Within 1-2 hours of nursing interventions, the patient will maintain or improve airway clearance as evidenced by absence of signs of respiratory distress and maintain optimal breathing. After 3 days, the patient will demonstrate behaviors to improve airway clearance and recovery.

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TAYABAN, KENNETH JAKE, Q.
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467 views2 pages

Student Nurse

The patient, a 74-year-old male, presented with difficulty breathing and abnormal breath sounds diagnosed with bronchial asthma in acute exacerbation. Within 1-2 hours of nursing interventions, the patient will maintain or improve airway clearance as evidenced by absence of signs of respiratory distress and maintain optimal breathing. After 3 days, the patient will demonstrate behaviors to improve airway clearance and recovery.

Uploaded by

TAYABAN, KENNETH JAKE, Q.
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Student Nurse: Kenneth Jake Q.

Tayaban Year/Section: 3C (Group4)

Patient’s Initials: B.B. Age: 74 Sex: Male Date: September 29, 2023

Chief Complaints: Difficulty of breathing Diagnosis: BAIAE (bronchial asthma in acute exacerbation)

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Ineffective STG: Independent: STG:


airway
“Nahihirapan clearance Within 1-2 hours ·1. Auscultate breath Some degree of “The goal was met”
ako related to of nursing sounds. Note bronchospasm
huminga” as increased interventions the adventitious is present with After 1-2 hours of nursing interventions
verbalized by production of patient will breath sounds obstructions in the patient maintains or improve airway
the secretions maintain or like wheezes, airway and may clearance as evidenced by absence of
patient. manifested by improve airway crackles and or may not be signs respiratory distress and maintain
abnormal clearance as rhonchi. manifested in optimal breathing pattern as evidenced
Objective: breath sounds. evidenced by adventitious by relaxed breathing and normal
absence of signs breath sounds. respiratory rate
• Difficulty of respiratory
breathing. distress and will 2. Elevate head of 2. Elevation of the LTG:
• Abnormal maintain optimal the bed, have bed facilitates
breath breathing pattern patient lean on respiratory After 3 days of
sounds. as evidenced by overbed table or function by use nursing
relaxed breathing sit on edge of the of gravity. interventions,
and normal bed. the patient will
• V/S taken as respiratory rate demonstrate
follows: 3. Keep 3. Precipitators of behaviors to
T: 37.3 environmental allergic type of improve airway
P: 82 LTG: pollution to a respiratory clearance.
R: 25 minimum like reactions that
BP: 110/80 After 3 days of dust, smoke and can trigger or
nursing feather pillows, exacerbate
interventions, according to onset of acute
the patient will individual episode.
demonstrate situation.
behaviors to
improve airway · 4. Encourage or 4. Provides patient
clearance. assist with with some
abdominal or means to cope
pursed lip with or control
breathing dyspnea and
exercises. reduce air
tapping.

5. Assist with 5. Coughing is


measures to most effective
improve in an upright
effectiveness of position after
cough effort. chest
percussion.

6. Increased fluid 6. Hydration helps


intake to 3000 ml/ decrease the
day. Provide viscosity of
warm or tepid secretions,
liquids. facilitating
expectoration.
Using warm
liquids may
decrease
bronchospasm.

Dependent:

1. Administer 1. To reduce the


Bronchodilators as prescribed. viscosity of
secretions.

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