John Smith 67 Widowed Roman Catholic

Patient
“Sometimes I have times where I choke” Parkinson’s Disease

3/27/20 Maslow’s Hierarchy of Subjective: Risk for injury related to Within 8hrs of my nursing intervention, the Independent: NANDA 14th - Goal met
Needs: “Sometimes I have times Parkinson’s disease as pt will be able to: - Observe pt and assess energy - Energy ability decreases with age and chronic Edition
level and endurance, and how diseases.
where I choke” AVB pt evidenced by these affect respiratory status. - Within 8hrs of my
Physical Needs bronchospasm. 1) achieve the ability to maintain patent nursing intervention, the
Objective: airways and respiratory status. - Assess respiratory status for - For baseline data. pt was able to:
- dyspnea rate, depth, ease, use of
- bronchospasms 2) will have clear breath sounds to accessory muscles, and work 1) achieve the ability to
of breathing.
- increased breathing auscultation and will have respiratory maintain patent airways
effort status parameters with optimal air - Auscultate the lung fields for - Wheezing results from squeezing of air past and respiratory status.
- coughing exchange. the presence of wheezes, the narrowed airways during expiration, caused
crackles, rhonchi, or decreased by bronchospasms, edema, and obstructive 2) will have clear breath
breath sounds. secretions. Decreased breath sounds may sounds to auscultation
indicate alveolar collapse with little to no air and will have respiratory
exchange in the lung area being auscultated and
results in poor ventilation. status parameters with
optimal air exchange.
- Assess pt for pallow or - May indicate hypoxemia.
cyanosis in nail beds and/or
around the mouth

- Position pt in high-fowler’s or - Promotes maximal lung expansion.

semi-fowler/s position, if
possible.

- Turn the pt every 2 hours. - Promotes relaxation of bronchial smooth

muscles to decrease spasm, dilates airways to
improve ventilation, and maximizes air
exchange.

- Encourage deep breathing - Assists in lung expansion and helps in

and coughing exercises every 2 dislodgement of secretions for easier
hours. expectoration.

Dependent: - To provide supplemental oxygen to benefit pt.

- Administer oxygen as
ordered by physician.

Alexa-Rae P. Zagado SNBC BSN-III 3/27/20

Ronald Ramo RN, MAN