CHAPTER 29 Obstructive Pulmonary Diseases

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NURSING CARE PLAN 29-1

Patient with Asthma
NURSING DIAGNOSIS
PATIENT GOALS

Ineffective airway clearance related to bronchospasm, excessive mucus production, tenacious secretions, and fatigue
as evidenced by ineffective cough, inability to raise secretions, adventitious breath sounds
1. Maintains clear airway with removal of excessive secretions
2. Experiences normal breath sounds and respiratory rate

OUTCOMES (NOC)
Respiratory Status: Airway Patency

INTERVENTIONS (NIC) AND RATIONALES

Asthma Management

Determine baseline respiratory status to use as a comparison point.

Monitor rate, rhythm, depth, and effort of respiration to determine need for intervention and
evaluate effectiveness of interventions.
Observe chest movement, including symmetry, use of accessory muscles, and supraclavicular
and intercostal muscle retractions, to evaluate respiratory status.
Auscultate breath sounds, noting areas of decreased/absent ventilation and adventitious sounds,
to evaluate respiratory status.
Administer medication as appropriate and/or per policy and procedural guidelines to improve
respiratory function.
Coach in breathing/relaxation techniques to improve respiratory rhythm and rate.
Offer warm fluids to drink to liquefy secretions and promote bronchodilation.

Respiratory rate _____

Respiratory rhythm _____
Moves sputum out of airway _____
Ease of breathing _____

Measurement Scale

1 = Severely compromised
2 = Substantially compromised
3 = Moderately compromised
4 = Mildly compromised
5 = Not compromised

NURSING DIAGNOSIS
PATIENT GOALS

Anxiety related to difficulty breathing, perceived or actual loss of control, and fear of suffocation as evidenced by restlessness,
elevated pulse, respiratory rate, and blood pressure
1. Reports decreased anxiety with increased control of respirations
2. Experiences vital signs within normal limits

OUTCOMES (NOC)
Anxiety Level

INTERVENTIONS (NIC) AND RATIONALES

Anxiety Reduction

Restlessness _____
Increased blood pressure _____
Increased pulse rate _____
Increased respiratory rate _____
Verbalized anxiety _____
Facial tension _____

Measurement Scale
1 = Severe
2 = Substantial
3 = Moderate
4 = Mild
5 = None

Identify when level of anxiety changes to determine possible precipitating factors.

Use calm, reassuring approach to provide reassurance.
Stay with patient to promote safety and reduce fear.
Encourage verbalization of feelings, perceptions, and fears to identify problem areas so appropriate
planning can take place.
Provide factual information concerning diagnosis, treatment, and prognosis to help patient know
what to expect.
Instruct patient in the use of relaxation techniques to relieve tension and to promote ease of respirations.

NURSING DIAGNOSIS
PATIENT GOALS

Deficient knowledge related to lack of information and education about asthma and its treatment as evidenced by frequent
questioning regarding all aspects of long-term management
1. Describes the disease process and treatment regimen
2. Demonstrates correct administration of aerosol medications
3. Expresses confidence in ability for long-term management of asthma

OUTCOMES (NOC)
Asthma Self-Management

INTERVENTIONS (NIC) AND RATIONALES

Asthma Management

Describes causal factors _____

Initiates action to avoid and manage
personal triggers _____
Seeks early treatment of infections _____
Monitors peak flow routinely _____
Monitors peak flow when symptoms occur _____
Makes appropriate medication choices _____
Demonstrates appropriate use of inhalers,
spacers, and nebulizers _____
Self-manages exacerbations _____
Reports uncontrolled symptoms to health care
provider _____

Determine patient/family understanding of disease and management to assess learning needs.

Teach patient to identify and avoid triggers as possible to prevent asthma attacks.
Encourage verbalization of feelings about diagnosis, treatment, and impact on lifestyle to offer
support and increase compliance with treatment.
Educate patient about the use of the peak expiratory flow rate (PEFR) meter at home to promote
self-management of symptoms.
Instruct patient/family on antiinflammatory and bronchodilator medications and their appropriate
use to promote understanding of effects.
Teach proper techniques for using medication and equipment (e.g., inhaler, nebulizer, peak flow
meter)* to promote self-care.
Assist in the recognition of signs/symptoms of impending asthmatic reaction and implementation
of appropriate response measures to prevent escalation of attacks.
Establish a written plan with the patient for managing exacerbations to plan adequate treatment
of future exacerbations.

Measurement Scale

1 = Never demonstrated
2 = Rarely demonstrated
3 = Sometimes demonstrated
4 = Often demonstrated
5 = Consistently demonstrated
*See Tables 29-7, 29-8, 29-10 and Fig. 29-7.