1. Nursing Diagnosis: Ineffective airway clearance related to bronchospasm and increased production of secretions as manifested by deep breathing, increased respiratory rate (30 bpm), use of accessory muscles in breathing, with abnormal breath sounds (wheeze and rales), with chest retractions, coughing and the verbalization of “kasla lang adda nakasullat ditoy karabukob ko”. Nursing Inference: In asthma, there will be an ineffective airway clearance brought about by the bronchospasm and increased production in secretions. Bronchospasm can be defined as constriction of the air passages of the lung by spasmodic contraction of the bronchial muscles caused by the different factors such as emotional stress, exercise, respiratory infection, allergens, irritants, foods, drugs, and occupation. Increased mucus production also happens when there is a release of leukotrienes of the mast cells which the main role is to activate mucus production of the mucus membrane. Nursing Goal: After 30 minutes to 2 hours of rendering nursing interventions, the client’s airway will be cleared as will be manifested by the absence of deep breathing, respiratory rate within normal range, breathing without the use of accessory muscles, no abnormal breath sounds, no chest retractions and the verbalization of “nalag-an iti panaganges kon”.
Nursing Interventions:
|Interventions |Rationale |
|Administer O2 inhalation as ordered and regulate it accurately.|To deliver adequate O2 needed by the body cells in normal|
| |amount |
|Administer bronchodilators as ordered | |
| | |
| |Bronchodilators stimulate the relaxation of smooth muscle|
|Position the client in high or semi-fowlers position or in |of the irritated bronchioles. |
|orthopneic position | |
| |For better lung expansion |
|Increase fluid intake unless contraindicated | |
| |To liquefy secretions thereby easier expectoration. |
|Teach client to cough effectively | |
| |To aid in the gradual movement of secretions or |
| |expectoration |
|Encourage deep breathing and coughing exercises. | |
| |To improve chest expansion for further distribution of O2|
|Encourage the client to have enough rest and sleep. |and easier expectoration of secretions. |
| | |
|Keep environmental pollution to a minimum, e.g., dust, smoke, |To conserve energy. |
|and feather pillows, according to individual situation. | |
| |Precipitators of allergic type of
