Name of Patient: C.V Age: 1 year old Male Room/Bed No.

: 213-1
Chief Complaint: Bronchial asthma Physician: Dr. T
Diagnosis:

DATE CUES NEED NURSING DIAGNOSIS PATIENT OUTCOME NURSING INTERVENTIONS IMPLEMENTATION EVALUATION
TIME

M Subjective: A Ineffective breathing After 4 hours of 1.) Monitor Oxygen Saturation

A “Naglisod man C pattern related to nursing intervention using Pulse Oximeter.
R gud na sya ug T bronchial asthma as the patient will be able R: Oxygen Saturation of less
C ginahawa I evidence by dyspnea, to established than 90% indicates problems
H maong gidala V fast breathing, respiratory rate within with oxygenation.
namo sya diri I expiratory wheezes normal limits. 2.) Elevate head of the bed,
0 ospital, naa pud T and tachypnea. encourage early ambulation or
5 na sya asthma” Y change the client’s position
as verbalized every 2 hours.
2 by the mother. & R: It will allow to take
0 advantage of the gravity
2 Objective: E decreasing pressure on the
0 -dyspnea X diaphragm and enhancing
@ -fast breathing E drainage of/ventilation to
RR: 51 bpm R different lung segments.
CR: 155 bpm C 3.) Encourage parents to
-expiratory I prepare warm water for
wheezing S bathing and use humidifier.
-irritable E R: to help open the airways
-tachypnea and ease the breathing.
-presence of 3.) Position the child sitting or
O2 inhalation upright when giving sips of
via facemask water.
-oxygen R: Sitting up straight will
saturated help to open the airways,
machine making it easier for air to move
through the lungs.
-Prescription of 4.) Administer medications
salbutamol given and prescribed assuring
nebulization, its right dose, right time and
Ipratropium right patient.
Bromide R: It is an important tool for
nebulization. ensuring the health of these
individuals as well as
managing their health care
costs
5.) Observe for breathing
patterns.
R: Unusual breathing patterns
may imply an underlying
disease process or
dysfunction.
6.) Monitor the respiratory rate
as well as its corresponding
rate and rhythm.
R: Changes in the respiratory
rate and rhythm may indicate
an early sign of impending
respiratory distress.
7.) Encourage watcher to pray
with the child.
R: to strengthen spiritual
relationship
8.) Monitor for diaphragmatic
muscle fatigue or weakness
(paradoxical motion).
R: Paradoxical movement of
the abdomen (an inward
versus outward movement
during inspiration) is indicative
of respiratory muscle fatigue
and weakness
9.) Stay with the patient during
acute episodes of respiratory
distress.
R: This will reduce the patient’s
anxiety, thereby reducing
oxygen demand.
10.) Refer patient for
evaluation of exercise potential
and development of
individualized exercise
program.
R: Exercise promotes
conditioning of respiratory
muscles and patient’s sense
of well-being.
11.) Place patient with proper
body alignment for maximum
breathing pattern.
R: A sitting position permits
maximum lung excursion and
chest expansion.
12.) Encourage small frequent
meals.
R: This prevents crowding of
the diaphragm.