Nursing diagnosis Goal Intervention Patient out come

1. Ineffective airway clearance related The patient showed the Airway menagement: expected outcomes:
to airway spasm, secretion retention, ability to maintain the  Free the airway (suction)  There is no secret
amount of mucus cleanliness of the airway  Monitor the chest wall retraction  Lungs clear sound
 Monitor respiration rate
 Give a semi-Fowler position
2. Clear the airway:
 Listen to lung sounds
 Encourage the patient to drink warm
 Do suction
 Monitor oxygen delivery
 Evaluation of lung sounds after suction

2. Ineffective breathing pattern related Adequate patient's Airway management: result criteria:
to spasm of the airway, respiratory respiratory status  Monitor respiratory patients  Respiration rate is within
muscle fatigue  Monitor the use of additional respiratory muscles (chest normal limits
wall retraction)  Not seen the use of
 Monitor Vitas signs; respiration, pulse, blood pressure, additional respiratory
temperature muscles
 Position the patient in semi-Fowler position  No complaints of pain in
2. Oxygen Therapy: breathing
 Provide oxygen according to program
 Give oxygen through a nasal or face mask canul
 The flow of 1-6 liters / minute oxygen concentration
produces 24-44%
 The flow of 5-8 liters / minute oxygen concentration
produces 40-60%
 The flow of 8-12 liters / min oxygen concentration
produces 60-80%
 The flow of 8-12 liters / min oxygen concentration
producing 90%
3. Collaboration for bronchodilator therapy.

3. Activity intolerance related to The patient showed tolerant 1. Energy management:  No shortness of breath
imbalance of oxygen supplied to the state of activity  Determine the causes of fatigue on exertion
needs  Monitor respiratory (respiration, dyspnoea, pallor)  Able to move up
 Help clients choose the activities that can be done
 Recommended to increase the intake of nutrients
2. Monitor response of breathing during activity, assess abnormal
response in respiration, blood pressure, pulse
4-Knowledge deficit: about asthma, increase patient knowledge Assess the things that have been known to patients  Knowing trigger asthma
related to lack of information sources about asthma  Knowing about the
2. Assess the patient's condition before health education, do not things that need to be
provide health education, while patients in the state of attack. avoided
 Knowing the handling of
3. Education: the attack
 Explain the meaning of asthma
 Explain the trigger factor
 Describe the things that need to be avoided: elergan
factors, stress, excessive cold weather activity
 Explain how the handler during an asthma attack at home
 Evaluate what has been delivered

5. Anxiety related to crisis situations: he patient can control Lower levels of anxiety:  Patient's expression
changes in health status anxiety and increase coping  Listen to their patients relaxed
 Explain each will perform maintenance procedures  Vital signs are within
 Instruct the patient to accompany the family as a support normal limits
system during an asthma attack
2. Teach termination worried if stress can not be avoided:
 Turning his attention upward
 Respiratory control by drawing a deep breath (relaxation)
 Position your body relax
 Make a relaxed mood, relaxed facial expression

Done by :- zainab salman al-ameen 210028075