Patient A is a man, 57 years of age, he had an acute asthmatic attack.

For three weeks prior to admission, the patient had increasing difficulty with
cough with thick, white sputum, shortness of breath, syncope episodes associated with wheezing, and intermittent fevers up to 101 degrees F (37.8 degrees
C). Patient A is married and has five children. He has smoking history; he was forced to retire from his job 2 years ago because of his chronic obstructive lung
disease.

ASSESSMENT NURSING PLANNING (WITH RATIONALE IMPLEMENTATION EVALUATION

DIAGNOSI AND REFERENCE)
S
SUBJECTIVE CUES: GOAL OF CARE Assess past patterns of After 8 hours of nursing
The patient verbalized After 1 week of sleep in normal environment: intervention the client
that “Nahihirapan ako Ineffective nursing amount, bedtime rituals, has been able to:
maghinga kase barado intervention the depth, length, positions, aids,
ilong ko pati may client will and interfering agents. - Verbalized feel
Airway
ubo” I have a hard After 8 hours of nursing intervention - Assess respiratory status for of rested
time to breath because the client will: rate, depth, ease, use of
my nose is block and I Clearance accessory muscles, and work
have coughs.  Patient will achieve the return of breathing - achieve and
of and ability to maintain - Auscultate the lung fields for maintain a patent
OBJECTIVE CUES: patent airways and respiratory the presence of wheezes, airway.
status baselines. crackles (rales), rhonchi, or
- Restlessness decreased breath sounds.
noted  Patient will achieve and
- Monitor patient for cough and
maintain a patent airway. - achieve and
production of sputum, noting
- Changes in maintain a patent
 Patient will have clear breath amount, color, character, and
respiratory rate airway.
sounds to auscultation and will patient’s ability to expectorate
and depth
have respiratory status secretions, and the ability to
- Rhinorrhea parameters with optimal air cough. - have clear breath
exchange. - Position patient in high sounds to
- Decreased Fowler’s or semi-Fowler’s auscultation and
breath sounds  Patient will be compliant and position, if possible. will have
be able to accurately - Administer bronchodilators as
- respiratory status
administer medications on a ordered parameters with
-V/S taken as follows daily basis, preventing - Encourage fluids, up to 3-4 optimal air
T: 37.8 exacerbations of the disease
L/day unless contraindicated. exchange.
P: 70 process.
- Encourage deep breathing
R: 17
 Patient will be able to cough exercises and coughing
BP:120/90 exercises every 2 hours.
up secretions and perform
coughing and deep-breathing
 exercises.

Rationale
Changes may vary from minimal to
extreme caused by bronchial swelling,
increased mucus secretions caused by
oversecretion of goblet cells and
tracheobronchial infection, narrowing
of air passageways, and presence of
other disease states that complicates
the current condition.

Wheezing is caused by squeezing of

air past the narrowed airways during
expiration which is caused by
bronchospasms, edema, and secretions
obstructing the airways.Crackles or
rales, result from consolidation of
leukocytes and fibrin in the lung
causing an infection or by fluid
accumulation in the lungs.

Mucus color from yellow to green

may indicate the presence of infection.
Tenacious, thick secretions require
more effort and energy to expectorate
through coughing, and may actually
create an obstruction stasis that leads
to infection and respiratory changes.

https://nurseslabs.com/ineffective-
airway-clearance/
ASSESSMENT NURSING PLANNING (WITH RATIONALE IMPLEMENTATION EVALUATION
 DIAGNOSI AND REFERENCE)
S
SUBJECTIVE Ineffective GOAL OF CARE Assess past patterns of After 8 hours of
CUES: breathing After 1 week of sleep in normal environment: nursing intervention
The patient pattern nursing amount, bedtime rituals, the client has been
verbalized that intervention the depth, length, positions, aids, able to:
"Ma'am client will and interfering agents.
nahihirapan po After 8 hours of nursing intervention - record pt. vital signs every - Relaxed
akong huminga the client will: 2hours. breathing
paminsan, dahil - Patient will maintain optimal - auscultate patient breathing appearance
to sa ubo ko ata" breathing pattern as evidence sounds
I can breathe by - Assess patient oxygen stats - verbalizes of
sometimes feeling rested
because of my 1. Relaxed breathing
cough. - Normal
2. Normal respiratory rate respiratory
rate
3. Absence of dyspnea -Assess
OBJECTIVE the respiratory rate, depth, - Have Absence
CUES: rhythm. Rationale = changes in of dyspnea
- Different RI and rhythm may indicate an
breathin early sign of impending
g sound respiratory distress.
- Dyspnea
- Cough Planning
- Fever - assess breath sounds and
adventitious sounds such as
V/S taken as wheezing and stridor
follows
T: 37.8 - monitor oxygen saturation
P: 60
R: 15 Rationale
BP:130/90 - adventitious sound may
indicate a worsening condition
or additional complication
such as pneumonia
ASSESSMENT NURSING PLANNING (WITH RATIONALE AND IMPLEMENTATION EVALUATION
DIAGNOSIS REFERENCE)
SUBJECTIVE DISTURDED GOAL OF CARE Assess past patterns of After 1 week of nursing
CUES: SLEEPING After 1 week of sleep in normal environment: intervention the client has
The patient PATTERN nursing amount, bedtime rituals, been able to:
verbalized that “Di intervention the depth, length, positions, aids,
ako makahinga ng client will and interfering agents. - verbalizes of
Mabuti” I can’t After 1 week of nursing intervention the - Assess and record feeling rested
breathe well” client will: respiratory rate, depth.
Note the use of accessory
 Reduced tolerance for activity muscles, pursed-lip - Reduced tolerance
breathing, inability to for activity
 Participate in treatment regimen speak or converse.
within the level of - Participate in
ability/situation.
- Assess and routinely treatment regimen
OBJECTIVE CUES: monitor skin and mucous within the level of
- Restlessness Rationale membrane color. ability/situation.
noted - Thick, tenacious, copious
- Abnormal secretions are a major source of - Monitor changes in the
breathing impaired gas exchange in small level of consciousness
and mental status - Able to breath
airways. Deep suctioning may be
- Inability to well without using
required when the cough is
move accessory muscles.
ineffective for expectoration of - Monitor vital signs and
secretions
secretions. cardiac rhythm.
- Reduced - Cyanosis may be peripheral
tolerance for (noted in nail beds) or central - Auscultate breath sounds,
activity (noted around lips/or earlobes). noting areas of decreased
Duskiness and central cyanosis airflow and adventitious
indicate advanced hypoxemia. sounds
-V/S taken as follows - Restlessness, agitation, and
T: 36.8 anxiety are common - Monitor O2 saturation and
P: 70 manifestations of hypoxia. titrate oxygen to maintain
R: 15 Worsening ABGs accompanied by Sp02 between 88% to
BP:120/90 confusion/ somnolence are 92%.
indicative of cerebral dysfunction
due to hypoxemia
- Tachycardia, dysrhythmias, and - Elevate the head of the
changes in BP can reflect the bed, assist the patient to
effect of systemic hypoxemia on assume a position to ease
cardiac function. work of breathing.
- Oxygen delivery may be Include periods of time in
improved by upright position and a prone position as
breathing exercises to decrease tolerated. Encourage
airway collapse, dyspnea, and deep-slow or pursed-lip
work of breathing. Use of prone breathing as individually
position to increase Pao2. needed or tolerated.

https://nurseslabs.com/chronic- - Evaluate sleep patterns,
obstructive-pulmonary-disease- note reports of difficulties
copd-nursing-care-plans/2/ and whether patient feels
well rested. Provide quiet
environment, group care
or monitoring activities to
allow periods of
uninterrupted sleep; limit
stimulants such
as caffeine; encourage
position of comfort.

- Evaluate the level of

activity tolerance. Provide
a calm, quiet
environment. Limit
patient’s activity or
encourage bed or chair
rest during the acute
phase. Have patient
resume activity gradually
and increase as
individually tolerated.