Name of the Client: _Gaspar,Toby Age/Sex: _8 y.

o/Male Room #:_208

Dat Cues Nee Nursing Diagnosis Patient Outcome Nursing Impl Evaluation
e/ d Interventio em
Ti ns entat
me io n
S S: H Ineffective airway At the end of my 8 Assess 1 September
Difficulty in clearance related to hours nursing care, respiratory rate, 3,
E breathing E bronchospasms as the client will be able depth, and 2021
as evidenced by to: rhythm.
P verbalized A difficulty in @7AM
by the breathing. R: Changes in the
T client. L GOALS/OBJECTIVE respiratory rate GOAL
S: and rhythm may
E O: T indicate an early MET:
BP: Client will be able to sign of impending
M 100/60 H maintain airway respiratory The client
T: 36.7 patency as distress. 2 will
B °C P evidenced by clear verbalize
breath sound, Assess the reduction or
E E improved oxygen effectiveness of absence in
exchange, normal cough. difficulty in
R R rate and depth of breathing
RATIONALE: respiration, and R: Coughing is a and cardiac
2, C ability to effectively natural way to rate within
Bronchospasm cough out clear the throat normal
2 E occurs when the secretions. and breathing range,
0 muscles that line the passage of foreign absence or
2 P airways of the lungs Client will be able particles, irritants, reduction of
1 constrict or tighten, to identify and mucus. inspiratory
T reducing airflow by potential Bronchospasm is wheezing
@ 15% or more complications and one of the cause and ability
7A I initiate of an ineffective to resume
M appropriate cough. to activities.
O actions. The client
will be able
N to identify
/ and

H
M Assist the client to 3 avoid
assume to potential
A comfortable allergens
position that would
N trigger
R: Elevation of asthma
A head of the bed attack and
facilitates be able to
G respiratory 4 handle
function symptoms if
E recurrence
Keep comes,
M environment prompt
pollution to a follow up
E minimum checkup
according to and to
N individual always
situation. bring or
T have the
R: Precipitators of prescribed
allergic type of medication/
respiratory 5 s on hand in
reactions that can case
trigger or asthma
exacerbate onset occurs.
of acute episode.

Encourage deep
breathing and
coughing
exercises.

R: Helps loosen 6
excess
secretions and
contribute in
effective
clearing mucus
out of the lungs.

Administer
oxygen as
ordered.

R: Oxygen therapy
 corrects
hypoxemia, which
can be caused by
retained
respiratory
secretions.
7
Provide
supplement
al
humidificati
on

R: Breathing
exercises help
enhance
diffusion,
nebulizer
medications can
reduce
bronchospasm.

References:
● Huizen, J. (2017, November 27). What is a bronchospasm and what causes it? Medical News

Today. https://www.medicalnewstoday.com/articles/320162

● Md, H. I. R. N. (2021, March 6). RNspeak. RNspeak | Nursing Journal.

https://rnspeak.com/asthma-nursing-care-planncp-ineffective-airway-

clearance/

● Martin, P. B. (2020, January 9). 8 Asthma Nursing Care Plans.

Nurseslabs. https://nurseslabs.com/asthma-nursing-care-plans/2/