Name:_Ms.

Pepito_ Initial Complaint: bad asthma attack, chest tightness,_

Age:_39 yrs. old_ Sex:_F_ Status:_Married_ _cannot catch breath_____________
Birthday:_n/a_
Religion:_n/a_ Nationality:_n/a_

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS OUTCOME INTERVENTION RATIONALE EVALUATION

Subjective: Respiratory Distress After 8 hours of  Check patient’s  Changes in the After 8 hours of
“I am having a bad related to asthma nursing intervention, vital signs and respiratory rate nursing intervention,
asthma attack. My characteristic of and rhythm may
chest feels very tight  Patient will respirations. indicate an early  Patient maintained
and I cannot catch my maintain airway sign of impending airway patency as
breath” as verbalized patency as respiratory evidenced by clear
by the patient. evidenced by clear distress. breath sounds,
breath sounds, improved
Objective: improved oxygen  Check patient’s  Wheezes suggest oxygenation,
 difficulty breathing exchange, normal breath sounds. partial obstruction normal respiratory
 audible high- rate and depth of or resistance. rate, and effectively
pitched wheezing respiration, and While rhonchi coughed out
 difficulty speaking ability to may indicate secretions.
 expiratory wheezes effectively cough retained secretions
 scattered rhonchi out secretions. in the lungs.
 dyspnea
 chest tightness  Encourage patient  Coughing is a
 V/S: to cough. natural way to
BP- 142/96 mmHg clear the throat
RR- 34bpm and breathing
PR- 88bpm passage of foreign
SpO2- 86% particles, irritants,
and mucus.

 Teach deep  Helps loosen and

breathing exercises expectorate excess
and relaxation secretions and
techniques. contribute in
Provide adequate effective clearing
ventilation in the mucus out of the
room. lungs.

 Elevate the head of  To promote lung

the bed and assist expansion so the
the patient to semi- patient can
Fowler’s position. breathe properly.

 Administer  To maintain
supplemental maintain adequate
oxygen, as tissue oxygenation
prescribed. while minimizing
cardiopulmonary
work.
ASSESSMENT DIAGNOSIS OUTCOME INTERVENTION RATIONALE EVALUATION
Subjective: Anxiety related to After 8 hours of  Assess the  Increase anxiety After 8 hours of
“I have medications respiratory distress nursing intervention, patient’s anxiety may indicate an nursing intervention,
which I continue to level. early sign of
use from earlier  Patient will hypoxia.  Patient
hospitalization, verbalize a demonstrated calm
albuterol and reduction in level  Reassure the  Client’s anxiety behavior which
Vanceril, I have taken of anxiety patient that the will decrease as shows reduction in
them already but they experienced. prescribed he or she can anxiety level.
are not helping.” medications are understand the
“His boss needs to get  Patient will standard treatment  Patient verbalized a
a message to him to demonstrate interventions for regimen. reduction in level
inform him that I am reduced anxiety as asthma and they of anxiety
here.” as verbalized evidenced by a are usually experienced.
by the patient. calm demeanor and effective.
cooperative
Objective: behavior.  Reassure the  Reassuring patient
 difficulty breathing patient that she can help relieve
 audible high- will be apprehension.
pitched wheezing comfortable.
 difficulty speaking
 expiratory wheezes  Interact with  The presence of a
 dyspneic patient. Stay with trusted reliable
 chest tightness the patient. person may give
 V/S: the client a sense
 BP- 142/96 mmHg of security.
 RR- 34bpm
 PR- 88bpm  Inform the patient  To lessen the
 O2- 86% that her husband is patient’s anxiety.
already informed
that she’s in the
hospital.
ASSESSMENT DIAGNOSIS OUTCOME INTERVENTION RATIONALE EVALUATION
Subjective: Knowledge Deficit After 8 hours of  Tell patient to  To prevent After 8 hours of
“My husband just related to possible nursing intervention, wear mask when inhaling allergens nursing intervention,
started working for an allergens that doing laundry. that trigger the
asbestos removal triggered asthma  Patient will patient’s asthma  Patient verbalized
company about a attack verbalize attack. understanding of
month ago.” prevention
understanding
“I had my attack after  Tell patient to  To avoid exposure measures to avoid
doing my laundry”. as of prevention allergens.
segregate her to possible
verbalized by the measures to husband’s work allergens.
patient. avoid allergens. clothes when he
comes home and
Objective: put it in a plastic
 difficulty breathing bag.
 audible high-
pitched wheezing  Use liquid  Since detergent
 expiratory wheezes detergent instead powder is a
 dyspneic of detergent possible allergen
 V/S: powder. that triggered the
 BP- 142/96 mmHg patient’s asthma
 RR- 34bpm attack.
 PR- 88bpm
 O2- 86%  Pace the patient’s  To avoid fatigue.
activities. Provide
rest periods.

 Avoid physical  Physical exertion

exertion when can increase the
doing laundry. chance of asthma
attack.

 Tell patient to  To relieve asthma

always bring symptoms.
asthma relief
inhaler/
medication.