Download Plan of Care: 1. Key assessment facts for Nursing Diagnosis 1

Plan of Care:
1. Key assessment facts for Nursing Diagnosis 1 / Collaborative problem

Admission (9/19):
o SO2: 92% on room air
o Labored, shallow breathing with intercostals retractions and wheezes throughout.
Intermittent cough.
o Tachypnea (resp: 60/min)

Day of student care (9/21 at 0800):
o SO2: 93% (on 2L O2)
o Non-labored breathing of normal pattern and depth, no retractions and some
wheezes upon inspiration. Intermittent cough.
o Tachypnea (resp: 36/min)
Nursing Diagnosis: # 1 Physical

Impaired gas exchange related to inflammation of alveoli and excess secretions
secondary to asthma manifested by low oxygen saturation and ordered oxygen therapy
Patient goals or outcomes:
Patient will tolerate a wean off of O2 by 1830 as demonstrated by an O2 saturation of
92% or better on room air
Nursing / Health Care
Rationale
Interventions
 Nurse will ambulate
patient
 Asthma is in inflammatory disease characterized my
mucosal edema, increased viscid secretions, and smooth
muscle contraction which result in wheezing, dyspnea,
and cough (Copstead & Banasik, 2010, pg 539). The
increased secretions can lead to airway obstruction which
will cause O2 saturation to drop (Bowden & Greenberg,
2010, pg 699). Ambulation can assist in loosening the
secretions which will make it easier for the patient to
couch them up and improve their SO2 levels (Bowden &
Greenberg, 2010, pg 674-675).
 Nurse will encourage
patient to cough
 Excess production of mucus is can lead to airway
obstruction, crackles, and atelectasis in asthma patients
(Kovesi et al, 2010, pg 173). Encouraging the patient to
cough, particularly after respiratory treatments, can help
patient clear their airway (Bowden & Greenberg, 2010,
pg 674).
 Nurse will encourage
 Increasing the patient’s intake of clear fluids helps
patient to increase clear
prevent dehydration from the increased insensible losses
fluid intake
associated with mouth breathing and increased
respiratory rate and it also helps decrease viscosity of
secretions while increasing the ciliary action necessary to
help remove the secretions (Bowden & Greenberg, 2010,
pg 674).
 Nurse will administer
 Inhaled corticosteroids, such as Solu-Medrol, are the anti-
prescribed medications
inflammatory drug of choice for patient’s with persistent
and IV fluids,
asthma (Kovesi et al, 2010, pg 176). Bronchodilators,
monitoring for response
such as Albuterol, are used to help increase the
and side effects
effectiveness of cough and enhance the work of breathing
while IV fluids help maintain adequate hydration which
thins secretions (Bowden & Greenberg, 2010, pg 674).
 Nurse will monitor O2
 Regular monitoring of oxygen saturation enables early
saturation and assess
detection of abnormalities and allows nurse to monitor
respiratory functioning
treatments and interventions for effectiveness (Bowden &
regularly throughout day
Greenberg, 2010, pg 674). Conducting a complete
of care
respiratory assessment enables nurse to see patients status
and allows for evaluation of treatments (Bowden &
Greenberg, 2010, pg 674).
Evaluation of each Intervention
Modifications
Potential or
Actual
 Patient ambulated the halls with foster mother and SN x 3 times
during 12 hour shift.
 Patient coughed whenever his O2 saturation began to fall with
encouragement from mom and SN and even created a sort of game
 Goal
achieved, no
modifications
necessary
out of how many “nice coughs” he could do.
 Patient increased oral fluid intake from 120 mLs at 0800 to 240 mLs
at 1600. IV fluids were reduced to TKO.
 Patient tolerated medication administration well.
 Patient’s O2 saturation levels fluctuated between 93-96% on RA, his
respiration rate fluctuated between 24-36 r/min, and his breath sounds
were some wheezing on expiration.
Evaluation of Goals / Outcomes
Modifications
Potential or
Actual
 Patient tolerated weaning off of O2 by 1400 and maintained an O2
saturation of 93% or better on room air.
Goals met, no
modifications
necessary.