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Medical Diagnosis: Asthma

Subjective Data “I had to call the ambulance because I thought I was going to die.”

Objective Data O2 95, P 101, R 21, wheezing

Nursing Diagnosis Ineffective Airway Clearance related to bronchospasms as evidence by


adventitious lung sounds and changes in respiratory rate and rhythm.
Short Term Goal #1 Patient will maintain a patent airway for the next 12 hours.

Intervention 1) Give Albuterol (Proventil, Ventolin) 1-2 inhalations every 4-6 hr


(90 mcg/ inhaled dose) during asthma attack.
The drug can stop or reduce life-threatening bronchoconstriction, which
can occur anytime. Med surg pg553
2) Assist patient with clearing secretions starting @ 0700.
Monitor respiratory status; monitor airway patency and provide frequent
suctioning to remove bloody secretions. Saunders pg 598
3) Educate patient on how to use incentive spirometer @ 0800.
 For optimal lung expansion with the incentive spirometer, the client
should assume the semi-Fowler’s or high Fowler’s position.
 The mouthpiece should be covered completely and tightly while the
client inhales slowly, with a constant flow through the unit.
 The breath should be held for 5 seconds before exhaling slowly.
Encourage the use of the incentive spirometer. Saunders pg794
Evaluation Goal met

Short Term Goal #2 Patient will demonstrate effective coughing technique to clear secretions
within 1 hour.
Intervention 1) Educate patient on how to cough and deep breathe @ 0800.
 Breathe in through the nose.
 Breathe out through the mouth.
Encourage coughing and deep breathing Saunders pg794
2) Educate patient on how to use a flutter mucus clearing device @ 0800.
 Position head slightly back.
 Slowly breathe in deeper than a normal breath, and hold your breath
for 2-3 seconds.
 Put the flutter in your mouth and close your lips around the stem.
 Position the flutter at the proper angle and blow out a little faster and
longer than normal.
 Take a full, deep breath into lungs and hold breath for 2-3 seconds.
 Blow out forcefully through the device
 Repeat forceful exhalation 1 or 2 more times.
 Try to cough the mucous from your chest.
Flutter mucus clearance device (a small, hand-held plastic pipe with a
stainless steel ball on the inside) facilitates the removal of mucus and may
be prescribed Saunders pg471
3) Educate patient on Huff coughing @ 0800.
 Patient should take 3 or 4 deep breaths using pursed-lip and
diaphragmatic breathing. Leaning slightly forward, the patient should
cough 3 or 4 times during exhalation.
This is an effective coughing technique that conserves energy, reduces
fatigue, and facilitates mobilization of secretions. Saunders pg712
Evaluation Goal met

Short Term Goal #3 Patient will maintain an oxygen saturation level greater than or equal to 95%
for 5 hours.

Intervention 1) Administer nebulization as ordered


Rationale: Nebulizer: Delivers fine liquid mists of medication through a
tube or a mask that fits over the nose and mouth, using air or oxygen under
pressure. Saunders pg737
2) Continually monitor oxygen saturation starting @ 0700.
Rationale: Pulse oximetry is used to monitor oxygen saturation. Saunders
pg673
3) Increase fluid intake to 3000 mL per day @0700, 1200, 1500.
Rationale: Encourage hydration to thin secretions. Saunders pg99
Evaluation Goal met

Long Term Goal #1 Patient will verbalize understanding of irritants or factors that can contribute
to ineffective airway clearance within 10 days.
Intervention 1) Educate patient on allergens to avoid @ 1000 daily.
 Outdoor: Trees, shrubs, weeds, grasses, molds, pollen, air pollution,
spores
 Indoor: Dust, dust mites, mold, cockroach antigen
2) Educate patient on irritants to avoid @ 1000 daily.
 Irritants: Tobacco smoke, wood smoke, odors, sprays
3) Educate patient on medications that can trigger an asthma attack @
1000 daily.
 Medications: Aspirin, nonsteroidal antiinflammatory drugs, antibiotics,
beta blockers
Rationale: Box 39-4 Precipitants Triggering an Asthma Attack Saunders
pg467
Evaluation Goal met
Long Term Goal #2 Patient will explain disease state, recognizes need for medications, and
understands treatments available within 30 days.
Intervention 1) Educate patient on what Asthma is @ 1000 daily.
 Marked by airway inflammation and hyperresponsiveness to a variety
of stimuli or triggers
Rationale: FIGURE 54-10 Pathophysiology in asthma. Saunders pg710
2) Educate patient on importance of adhering to medication regime to
prevent future instances of acute an acute asthma attack @ 1000 daily.
Rationale: A nursing priority is to teach the patient how to be a partner in
asthma management by participating in therapies to improve GAS
EXCHANGE and by adhering to prescribed drug therapy. Med Surg pg562
3) Encourage patient to develop a plan of care with HCP @ 1000 daily.
Rationale: About developing an asthma action plan with the primary HCP
and what to do if an asthma episode occurs Saunders pg721
Evaluation Goal met

Long Term Goal #3 The patient will recognize early signs of an asthma attack and
begin taking medication within 7 days.

Intervention 1) Educate patient on early s/s of an asthma attack @ 0800 daily.


2) Educate patient on how to use a peak flowmeter @ 0800 daily.
Set the peak flowmeter at zero.
• Use a standing position, without leaning or supporting yourself
on anything, if possible.
• Take as deep a breath as you can.
• Place the mouthpiece of the meter in your mouth, taking care to
wrap your lips tightly around it.
• Blow your breath out through the mouthpiece as hard and as
fast as you are able. (If you cough, sneeze, or have any type of
interruption while you exhale, reset the meter and perform the
test again.)
• Reset and perform the test two additional times.
• The highest reading of the three is your current peak flow rate.
• Keep a record or graph of your peak flow rates and examine
these for trends.
Rationale: Measures maximum flow of air that can be forcefully exhaled in
1 second; child uses a peak expiratory flowmeter to determine a “personal
best” value that can be used for comparison at other times, such as during
and after an asthma attack. Using a Peak Flow Meter Chart 30-4 Med Surg
pg553
3) Educate the patient that if a red zone reading occurs when using the
peak flowmeter to immediately use the reliever drugs and seek
emergency help @ 0800 daily.
Rationale: Nursing Safety Priority Action Alert Med Surg pg552
Evaluation
References:

1. Asthma. Patient is c/o shortness of breath, chest tightness, productive cough

2. Initial assessment; Temperature, Lungs, o2

3. 15 years old, 11 months

4. 98 % percentile according to height and weight.

5. She weighed 206lbs, 5’8

6. Assessment, called father to come pick her up, given inhaler; albuterol
7. Albuterol 90mcg (base)/actuation (equivalent to 108mcg albuterol sulfate), 2 puffs PO, tolerated

well.

8. When to use her inhaler; avoid going outside in gym class

9. I enjoyed my experience with Mrs. Kielma. I was expecting a slower-paced environment

compared to W. G. Nunn. I thought kids under the age of 12 were the only ones that came to

the nurse’s clinic for headache and stomachaches. I was wrong. I do believe that a new nurse

would need experience at the hospital before becoming a school nurse.

Hannah Hayes

08/31/17

Valdosta High School

Valdosta High School rings their tardy bell at 0815. It has around 2,000 students. Their
roll recently went up by 300 due to the new school that will open next year. Mrs. Kielma is a
Registered Nurse who has over 25 years of experience. Before breakfast, 6 or 7 students that
have type 1 diabetes stopped by and checked their blood sugar. Mrs. Kielma makes every student
check it in front of her. In the past, she had students that would lie and say their blood sugar was
70 when it was 400. One student would go into the bathroom and run water over her ketone
dipstick so she would not have to go to the doctor.

A patient came in today that was having a hard time talking. She was at gym class, they
went outside, and she had an allergic reaction to something and it flared up her asthma. She was
out of school yesterday and was sent home today. We assessed her lungs and heard some
wheezing. She took two puffs of her inhaler. We called her father and he came and picked her
up. He mentioned that she had a specialist in Tallahassee that she was going to but he did not see
any improvement.

A patient came in today for some Ibuprofen and she mentioned that she had her baby
over summer break. Her baby was born at 21 weeks and his lungs were not fully developed.
Sadly, he did not make it. The patient showed us pictures of him in his casket. He had on a little
suite and Mrs. Kielma asked how they found something to fit his little body. She said her little
sister had a Barbie Ken doll and took the clothes off it. There were over 150 pictures of him. He
only weighed 14 oz. Something did not set right with me. When she told me her baby did not
make it, she was smiling. I have never had someone show me pictures of their deceased baby. It
did not seem to phase her at all. Mrs. Kialma had the same thoughts as I did. She said that a child
her age that has a pregnancy, may not have the mental capability of what is going on. The
medical staff at the hospital thought her body was not ready for a baby and that’s why she had
him so early.

Today was a good day. It was a lot like W. G. Nunn. I thought it would have been a
slower-pace but I was wrong. We may have seen more patients at the High school than the
elementary school. There was a bunch of headaches, cramps, and stomachaches. Every 5-10
minutes a child would walk in. Overall, I liked the experience. I am not sure if I liked working
with people under the age of 18. I feel like a lot of the kids their only come to the nurse to get out
of class. When I was in high school, which was only three years ago, I never went to the nurse. I
am looking forward to my other specialty days.
DIAGNOSTIC PROCEDURE INFORMATION
Diagnostic Procedure None performed.

Normal Results

Patient Results

Nursing Interventions
Pre-and Post-Procedure