Asthma Care Plan - notes PDF

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Asthma Care Plan By Michelle Noble Ineffective Breathing Pattern (Nursing Diagnosis) Risk factors Swelling and spasm of the bronchial tubes in response to inhaled irritants, infection, drugs, allergies or infection. Signs & symptoms Cough Cyanosis Dyspnea Loss of consciousness Nasal flaring Prolonged expiration Respiratory depth changes Tachypnea Use of accessory muscles Desired Outcomes Patient will maintain optimal breathing pattern, as evidenced by relaxed breathing. Nursing Interventions and Rationales ● Assess the client’s vital signs as needed while in distress.

BP and HR drops and respiratory failure may result. ●

Monitor oxygen saturation.

Normal oxygen saturation levels are considered 95-100%. ●

Maintain head of bed elevated.

This promotes maximum lung expansion and assists in breathing. ●

Assess for signs of dyspnea (flaring of nostrils, chest retractions, and use of accessory muscle).

Once the movement of air into and out of the lungs becomes challenging, the breathing pattern changes. ●

Assess breath sounds and adventitious sounds such as wheezes and stridor.

Diminishing wheezing and indistinct breath sounds are suggestive findings and indicate impending respiratory failure. ●

Assess for fatigue.

Fatigue may indicate distress, leading to respiratory failure. ●

Encourage client to use pursed-lip breathing for exhalation.

Pursed lip breathing improves breathing patterns by moving old air out of the lungs and allowing for new air to enter the lungs....