Lopez, Maria Sofia B.

10/18/2020

3-BSN-B Prof. Isanan

NURSING CARE PLAN:

You where an ICU nurse and your patient was as 21 years old male hook in mechanical vent and
with severe asthma episode. Do 2 NCP See attached file for vital signs and assessment.

NURSING PLANNING
ASSESSMENT DIAGNOSIS GOAL / NURSING RATIONALE EVALUATION
EXPECTED INTERVENTION
OUTCOME S
Objective: Ineffective After 8 hours -Monitored -Changes in After 8 hours of
BP:147/76 mmHg airway of nursing respiratory rate, the nursing
T:36.2 ˚C clearance intervention, depth, and respiratory intervention, the
P:76 bpm related to the patient rhythm every rate and patient was
R:36 cpm asthma as will be able to hour. rhythm may able to maintain
O2SAT: 98 evidenced by maintain indicate an airway patency
BP:147/76 airway early sign of as evidenced
mmHg, and patency as impending by normal rate
R:36 cpm. evidenced by respiratory and depth of
normal rate distress. respiration and
and depth of a normal blood
respiration -Monitored -This pressure after
and a normal oxygen assessment suctioning.
blood saturation prior provides an
pressure after to and after evaluation of
suctioning. suctioning using the
pulse oximetry. effectiveness
of therapy.

-Administered IV -IV fluid

fluids and therapy can
medication as be beneficial
ordered. for clients with
dehydration.
Medications
such as
bronchodilator
s and inhaled
corticosteroid
s may be
prescribed.

-Positioned head -to open or

appropriate for maintain open
age and airway in at-
condition rest or
 compromised
individual

-Pace the client’s -Break up

activities. activities into
smaller parts
and take rest
breaks in
between to
avoid fatigue.
increased
effort in
breathing
properly.

NURSING PLANNING
ASSESSMENT DIAGNOSIS GOAL / NURSING RATIONALE EVALUATION
EXPECTED INTERVENTIONS
OUTCOME
Objective: Ineffective After 8 hours -Monitored -Changes in After 8 hours
BP:147/76 mmHg breathing of nursing respiratory rate, the of nursing
T:36.2 ˚C pattern intervention, depth, and rhythm respiratory intervention,
P:76 bpm related to the patient every hour. rate and the patient
R:36 cpm respiratory will be able to rhythm may was able to
O2SAT: 98 muscle maintain indicate an maintain
fatigue as optimal early sign of airway
evidenced by breathing impending patency as
RR 36 cpm. pattern, as respiratory evidenced by
evidenced by distress. normal rate
relaxed -Monitored oxygen and depth of
breathing, saturation prior to -This respiration
and normal and after assessment and a normal
respiratory suctioning using provides an blood
rate or pulse oximetry. evaluation of pressure after
pattern. the suctioning.
effectiveness
-Maintained head of therapy.
of bed elevated.
- This
promotes
maximum
lung
expansion
and assists in
breathing.

- Administered - Short-acting
medication as beta2-
ordered by the agonists are
physician. bronchodilato
Short-acting beta- rs. They relax
2-adrenergic the muscles
agonist. lining the
Albuterol airways that
(Proventil, carry air to
Ventolin). the lungs;
Levalbuterol treatment of
(Xopenex). choice for
Terbutaline acute
(Brethine). exacerbation
Inhaled of asthma.
Corticosteroids.
Budesonide
(Pulmicort).
Fluticasone
(Flovent).
Beclomethasone
(Vancenase).
Mometasone
(Asmanex
Twisthaler).

- Anticipated the
need for
alternative
treatment if life-
threatening
bronchospasm
continues.
a. General
anesthesia a. General
b. Magnesium anesthesia is
sulfate. used when
c. Heliox (a there is both
helium-oxygen dynamic
mixture). hyperinflation
and profound
hypercapnia
that cannot
be corrected
by increasing
minute
ventilation.
b.
Magnesium
sulfate has
bronchodilati
ng and anti-
inflammatory
effects that
are
sometimes
used in the
treatment of
moderate to
severe
asthma in
children.
c. The use of
helium (a less
dense gas
than nitrogen)
causes
decrease
airway
resistance
thus lessens
the work of
breathing.