1. IV. Create a case and make a NCP using the different steps of the Nursing Process
2. Ineffective Breathing Pattern r/t
hyperventilation secondary to bronchospasm
Subjective:
“Hangak…”
“Naglisod ko ug ginhawa, kutas akong ginhawa.”
as stated by the client. 3. Impaired Gas Exchange r/t ventilation
1. Ineffective Airway Clearance r/t perfusion imbalance secondary to
brochospasm and accumulation of secretions >Dyspnea/difficulty in breathing
hyperventilation
Subjective: Objective:
Subjective:
“Naglisod ko ug ginhawa, kutas akong  Labored breathing
 Used of accessory muscle “Naglisod ko ug ginhawa, kutas akong
dughan. Gi-ubo ko” As stated by the client. dughan. Gi-ubo ko” As stated by the client.
 Restlessness
> Dyspnea/difficulty in breathing  Hyperventilation
 Productive cough > Dyspnea/difficulty in breathing
Objective:  Changes in RR, depth and rate: 42cpm
 Cyanotic/cool & clammy skin Objective:
 Labored breathing  Labored breathing
 Used of accessory muscle  Used of accessory muscle
 Restlessness  Restlessness
 Wide-eyed appearance  Wide-eyed appearance
 Hyperventilation  Hyperventilation
 Presence of adventitious breath sounds:  Presence of adventitious breath sounds:
 Rales/crackles on both lung fields Name: Crystal Clear Gender: Female  Rales/crackles on both lung fields
 Wheezing on inspiration  Wheezing on inspiration
 Productive cough Age: 14y/o
 Productive cough
 Difficulty vocalizing C/C: Difficulty of Breathing  Difficulty vocalizing
 Changes in RR: 42 cpm Diagnosis: Bronchial Asthma  Changes in RR: 42 cpm
 Cyanotic/cool & clammy skin  Cyanotic/cool & clammy skin
 Use of orthopneic position  Vital Signs:
 Temp: 37.0 C  Use of orthopneic position
 Reduced tolerance to activity  Reduced tolerance to activity
 PR: 136 bpm
 RR: 42 cpm
 BP: 100/70 mmHg

2. Name: Crystal Clear Gender: Female
6. Self-Care Deficit (hygiene and self-
toileting) r/t general weakness secondary to Age: 14y/o
4. Impaired Cardiopulmonary Tissue
hypoxic state C/C: Difficulty of Breathing Perfusion r/t alteration in gas exchange
Diagnosis: Bronchial Asthma secondary to bronchospasm
Subjective:  Vital Signs:
 Temp: 37.0 C Subjective:
“Hangak…” as stated by the client.  PR: 136 bpm
 RR: 42 cpm “Naglisod ko ug ginhawa, kutas akong
“Maglisod man gyud ni siya ug lihok-lihok kay  BP: 100/70 mmHg ginhawa.” as stated by the client.
naglisod siya ug ginhawa, ako na lang siyang
tabangan.” as stated by SO. >Dyspnea/difficulty in breathing
> Dyspnea/difficulty in breathing Objective:
Objective:  Labored breathing
5. Fatigue r/t poor physical condition  Used of accessory muscle
 Labored breathing  Restlessness
 Used of accessory muscle secondary to generalized weakness due to
 Hyperventilation
 Restlessness/confusion hypoxic states  Fluctuating Oxygen Saturation: <90%
 Wide-eyed appearance (without Oxygen), >90% (with oxygen
 Hyperventilation Subjective: supplementation)
 Inability to perform activities such as  Changes in RR, depth and rate: 42cpm
bathing and tooth brushing “Kapoy man magsige ug lihok”, as verbalized  Cyanotic/cool & clammy skin
 Weakened state by patient.  Pallor
 Unable to go to CR
> Dyspnea/difficulty in breathing
Objective:
 Labored breathing
 Hyperventilation
 Changes in RR, depth and rate
 Cyanotic/cool & clammy skin
 Apprehension
 Weak appearance
 Drowsy
 Unable to perform activities

3. NURSING CARE PLAN
Identified Problem: Patient reports difficulty in breathing with cough
Nursing Diagnosis: Ineffective Airway Clearance r/t brochospasm and accumulation of secretions
CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
Subjective: Short Term Objective: Independent: STO:
Within 8 hours of nursing  Auscultated breath sounds. Noted  Bronchospasm is present with obstruction Outcome Partially Met:
“Naglisod ko ug ginhawa, care, the patient will be adventitious breath sounds. in airway and may/may not be manifested After the 8 hours of
kutas akong dughan. Gi-ubo able to expectorate with adventitious breath sounds. nursing care, the patient
ko” As stated by the client. secretions readily and was able to expectorate
demonstrate reduction of  Assessed and monitored respiratory  Respirations may be shallow and rapid, secretions, partially
> Dyspnea/difficulty in congestion as evi-denced rate. with prolonged expiration in comparison to relieved of congestion as
breathing by noiseless respiration, inspiration. Tachypnea may be present. evidenced by improved
reduction of adventitious oxygen exchange
breath sounds, &  Assisted patient to assume position  Elevation of HOB facilitates respiratory (absence of cyanosis,
Objective: improved oxygen of comfort (moderate high-back function by use of gravity, decreasing oxygen saturation >
 Labored breathing exchange (absence of rest). Changed positions every 2 pressure of diaphragm and enhancing 90%) and reduced
 Used of accessory muscle cyanosis, oxygen hours. ventilation of different lung segments. adventitious breath
 Restlessness saturation > 90%) after sounds, but still with
 Wide-eyed appearance providing appropriate  Kept environmental pollution to a  Precipitation of allergic type of respiratory increased respirations.
 Hyperventilation nursing care. minimum (dust, smoke, allergens) reactions that can trigger onset of acute
 Presence of adventitious according to individual situation. episode.
breath sounds: LTO:
 Rales/crackles on both Long Term Objective:  Taught and encourage deep-  Provides patient with some means to cope Outcome Met:
lung fields Within the 3-day nursing breathing and coughing exercises. with or control dyspnea and reduce air After the 3-day nursing
 Wheezing on inspiration care, the client will be traffic. care, the client was able
 Productive cough able to maintain patent to maintain patent airway
 Difficulty vocalizing airway with breath  Increased fluid intake to 3000ml/day  Hydration helps decrease the viscosity of (but with reduced breath
 Changes in RR sounds clear and within cardiac tolerance. secretions, facilitating expectoration. Fluids sounds) and potential
 Cyanotic/cool & clammy potential complications Recommended intake of fluids during meals can increase gastric compli-cations were
skin are prevented between, instead of during, meals. distention and pressure on the diaphragm. prevented after
 Use of orthopneic position (pneumothorax, cardiac Provided warm/tepid liquids. Using warm liquids may decrease independent and
 Reduced tolerance to arrest, respiratory failure, bronchospasms. collaborative nursing
activity etc.) after providing intervention was done.
 Vital Signs: appropriate nursing and  Observed for signs and symptoms  To identify infectious process and promote
 Temp: 37.0 C collaborative of infections. timely interventions.
 PR: 136 bpm interventions.
 RR: 42 cpm Collaborative:
 BP: 100/70 mmHg  Administered medications as
indicated:

4. > Bronchodilators: salbutamol  Inhaled anticholinergic agents are
considered the first-line of meds for asthma
and other COPD - because they have a
longer duration of action w/ less toxicity of
potential.
> Methylxanthine derivatives:  Decreases mucosal edema and smooth
aminophylline muscle spasm by indirectly increasing
cyclic Adenosine Monophosphate (AMP).
May reduce muscle fatigue/respiratory
failure by increasing diaphragmatic
contractility.
> Leukotriene antagonist:  Reduces leukotriene activity to limit
Montelukast inflammatory response.
> Antiinflammatory: budesonide  Decreases local airway inflammation and
edema by inhibiting effects of histamine
and other mediators.
> Antimicrobials: cephalosporins  Antimicrobials may be indicated for control
of respiratory infection/pneumonia.
Enhances airflow and improve outcome.
 Provided supplemental  Enhances expectoration of sputum,
humidification: partial rebreather improve pulmonary function, and reduces
mask, 6L/min; nebulization. lung volumes.
 Assisted in respiratory treatment:  Breathing exercises help enhance diffusion;
chest physiotherapy. nebulizer meds can reduce bronchospasm
and stimulate expectoration.
 Monitored pulse oximetry, CXR.  Establishes baseline for monitoring
progression/regression of disease process
and complications.
Pulse oximetry- can detect changes in
Oxygen saturation.

5. NURSING CARE PLAN
Identified Problem: Due to the difficulty in breathing and coughing, adventitious breath sounds are determined upon auscultation in both lung fields, hypoxia is present.
Nursing Diagnosis: Ineffective Breathing Pattern r/t hyperventilation secondary to bronchospasm
CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
Subjective: Short Term Objective: Independent: Short Term Objective:
“Hangak…” Within the 8 hours of  Auscultated breath sounds. Noted  Bronchospasm is present with obstruction
“Naglisod ko ug ginhawa, nursing care, the patient adventitious breath sounds. in airway and may/may not be manifested Outcome met.
kutas akong ginhawa.” as will be free of cyanosis with adventitious breath sounds. Within the 8 hours of
stated by the client. and other signs and nursing care, the patient
symptoms of hypoxia  Count patient RR in one full minute.  Respirations may be shallow and rapid, was free of cyanosis and
>Dyspnea/difficulty in (confusion, restlessness) with prolonged expiration in comparison to other signs and
breathing after providing inspiration. Tachypnea may be present. symptoms of hypoxia
appropriate nursing care. (confusion, restlessness)
 Assisted patient to assume position  Elevation of HOB facilitates respiratory after providing
Objective: of comfort (moderate high-back function by use of gravity, decreasing appropriate nursing care.
 Labored breathing rest). Changed positions every 2 pressure of diaphragm and enhancing
 Used of accessory muscle hours. ventilation of different lung segments.
 Restlessness Long Term Objective: Long Term Objective:
 Wide-eyed appearance Within the 3-day nursing  Kept environmental pollution to a  Precipitation of allergic type of respiratory
 Hyperventilation care, the client will be minimum (dust, smoke, allergens) reactions that can trigger onset of acute Outcome met
 Presence of adventitious able to establish and according to individual situation. episode. Within the 3-day nursing
breath sounds: maintain normal or care, the client was able
 Rales/crackles on both effective respiratory  Taught and encourage deep-  Provides patient with some means to cope to establish and maintain
lung fields pattern and be free of breathing and coughing exercises with or control dyspnea and reduce air normal or effective
 Wheezing on inspiration potential complications and use of purse-lipped breathing. traffic. respiratory pattern and
 Productive cough (pneumothorax, cardiac free of potential
 Difficulty vocalizing arrest, respiratory failure,  Kept resuscitation bag at bedside.  Provides adequate ventilation when patient complications
 Changes in RR, depth and etc.) after providing requires it. (pneumothorax, cardiac
rate appropriate nursing and arrest, respiratory failure,
 Cyanotic/cool & clammy collaborative  Observed for signs and symptoms  To identify infectious process and promote etc.) after providing
skin interventions. of infections. timely interventions. appropriate nursing and
 Use of orthopneic position collaborative
 Apprehension Collaborative: interventions.
 Reduced tolerance to  Provided supplemental  Enhances expectoration of sputum,
activity humidification: partial rebreather improve pulmonary function, and reduces
 Vital Signs: mask, 6L/min; nebulization. lung volumes.
 Temp: 37.0 C
 PR: 136 bpm  Monitor Arterial Blood Gases, pulse  Establishes baseline for monitoring
 RR: 42 cpm oximetry, CXR. progression/regression of disease process

6.  BP: 100/70 mmHg and complications.
Pulse oximetry- can detect changes in
Oxygen saturation.
NURSING CARE PLAN
Identified Problem: Due to the difficulty in breathing and coughing, adventitious breath sounds are determined upon auscultation in both lung fields, hypoxia is present.
Nursing Diagnosis: Impaired Gas Exchange r/t ventilation perfusion imbalance secondary to hyperventilation
CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
Subjective: Short Term Objective: Independent: Short Term Objective:
“Hangak…” Within the 8 hours of  Auscultated breath sounds. Noted  Bronchospasm is present with obstruction
“Naglisod ko ug ginhawa, nursing care, the patient adventitious breath sounds. in airway and may/may not be manifested Outcome partially met.
kutas akong ginhawa.” as will demonstrate with adventitious breath sounds. Within the 8 hours of
stated by the client. improved ventilation and nursing care, the patient
oxygenation as  Counted patient RR in one full  Respirations may be shallow and rapid, will demonstrate
> Dyspnea/difficulty in evidenced by SaO2 minute. with prolonged expiration in comparison to improved ventilation and
breathing >90%, respiratory rate inspiration. Tachypnea may be present. oxygenation as
within 16-20 cpm, evidenced by SaO2
decreased adventitious  Assessed skin and mucous  Cyanosis may be peripheral ( noted in >90%, , decreased
Objective: breath sounds and membrane color. nailbeds) or central (noted around lips or adventitious breath
 Labored breathing absence of cyanosis after earlobes). sounds and absence of
 Used of accessory muscle providing appropriate cyanosis after providing
 Restlessness/confusion nursing intervention.  Monitored level of  Restlessness and anxiety are common appropriate nursing
 Wide-eyed appearance consciousness/mental status. manifestations of hypoxia. intervention. But
 Hyperventilation respiratory rate is not
 Presence of adventitious  Evaluated level of activity tolerance.  During acute respiratory distress, patient within 16-20 cpm
breath sounds: Provided calm, quiet environment. may be totally unable to perform basic self- (42cpm).
 Rales/crackles on both Limited patient’s activity and care activities because of hypoxemia and
lung fields Long Term Objective: encouraged bed rest during acute dyspnea. Rest interspersed with care
 Wheezing on inspiration Within the 3-day nursing phase. activities remains an important part of Long Term Objective:
 Changes in RR, depth and care, the client will be treatment regimen.
rate able to establish and Outcome met.
 Cyanotic/cool & clammy maintain normal or  Assisted patient to assume position  Elevation of HOB facilitates respiratory Within the 3-day nursing
skin effective respiratory of comfort (moderate high-back function by use of gravity, decreasing care, the client was able
 Use of orthopneic position pattern and be free of rest). Changed positions every 2 pressure of diaphragm and enhancing to establish and maintain
 Apprehension potential complications hours. ventilation of different lung segments. normal or effective
 Diaphoretic (pneumothorax, cardiac respiratory pattern and
 Nasal Flaring arrest, respiratory failure,  Kept environmental pollution to a  Precipitation of allergic type of respiratory free of potential
 Fluctuating Oxygen etc.) after providing minimum (dust, smoke, allergens) reactions that can trigger onset of acute complications

7. Saturation: <90% (without appropriate nursing and according to individual situation. episode. (pneumothorax, cardiac
Oxygen), >90% (with collaborative arrest, respiratory failure,
oxygen supplementation) interventions.  Taught and encourage deep-  Provides patient with some means to cope etc.) after providing
 Vital Signs: breathing and coughing exercises with or control dyspnea and reduce air appropriate nursing and
 Temp: 37.0 C and use of purse-lipped breathing. traffic. collaborative
 PR: 136 bpm interventions.
 RR: 42 cpm  Kept resuscitation bag at bedside.  Provides adequate ventilation when patient
 BP: 100/70 mmHg requires it.
 Observed for signs and symptoms  To identify infectious process and promote
of infections. timely interventions.
Collaborative:
 Provided supplemental  Enhances expectoration of sputum,
humidification: partial rebreather improve pulmonary function, and reduces
mask, 6L/min; nebulization. lung volumes.
 Monitored pulse oximetry, CXR.  Establishes baseline for monitoring
progression/regression of disease process
and complications.
Pulse oximetry- can detect changes in
Oxygen saturation.
NURSING CARE PLAN
Identified Problem: Hypoxia leading to cyanosis
Nursing Diagnosis: Impaired Cardiopulmonary Tissue Perfusion r/t alteration in gas exchange secondary to bronchospasm
CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
Subjective: Short Term Objective: Independent: Short Term Objective:
“Hangak…” Within the 8 hours of  Auscultated breath sounds. Noted  Bronchospasm is present with obstruction Outcome met.
“Naglisod ko ug ginhawa, nursing care, the patient adventitious breath sounds. in airway and may/may not be manifested After the 30-minute
kutas akong ginhawa.” as will be able to identify and with adventitious breath sounds. health teaching the
stated by the client. demonstrate ways and patient was able to
interventions that will help  Count patient RR in one full minute.  Respirations may be shallow and rapid, identify and perform
>Dyspnea/difficulty in improve her circulation with prolonged expiration in comparison to interventions (deep-
breathing after 30 minutes of health inspiration. Tachypnea may be present. breathing exercises,
teaching. coughing, pursed-lip
 Assisted patient to assume position  Elevation of HOB facilitates respiratory breathing exercises) that
Objective: of comfort (moderate high-back function by use of gravity, decreasing aided in her circulation

8.  Labored breathing rest). Changed positions every 2 pressure of diaphragm and enhancing status.
 Used of accessory muscle hours. ventilation of different lung segments.
 Restlessness Long Term Objective:
 Wide-eyed appearance Within the 3 days of  Kept resuscitation bag at bedside.  Provides adequate ventilation when patient Long Term Objective:
 Hyperventilation nursing care, the patient requires it. Outcome met.
 Presence of adventitious will demonstrate After 3-day nursing care,
breath sounds: improved perfusion and Patient Health Teaching: the patient was able to
 Rales/crackles on both circulation as evidenced  Taught and encourage deep-  Provides patient with some means to cope maintain improved
lung fields by normal skin color, breathing and coughing exercises with or control dyspnea and reduce air perfusion and circulation
 Wheezing on inspiration reduction of breathing and use of purse-lipped breathing. traffic. as evidenced by normal
 Fluctuating Oxygen difficulty, relaxed state, skin color, SaO2 at 96%,
Saturation: <90% (without SaO2 >90% and absence  Taught patient about the treatment  To provide information on how the patient decreased breathing
Oxygen), >90% (with of cyanosis after regimen and disease process. will be able to prevent disease recurrence. difficulty, and patient is
oxygen supplementation) providing appropriate at relaxed state.
 Productive cough nursing and medical  Encouraged increase in total fluid  Hydration helps decrease the viscosity of
 Difficulty vocalizing intervention. intake to at least 3000 mL/day, secretions, facilitating expectoration. Fluids
 Changes in RR, depth and within cardiac tolerance. during meals can increase gastric
rate distention and pressure on the diaphragm.
 Cyanotic/cool & clammy
skin  Kept environmental pollution to a  Precipitation of allergic type of respiratory
 Pallor minimum (dust, smoke, allergens) reactions that can trigger onset of acute
 Use of orthopneic position according to individual situation. episode.
 Apprehension
 Reduced tolerance to Collaborative:
activity  Provided supplemental  Enhances expectoration of sputum,
 Vital Signs: humidification: partial rebreather improve pulmonary function, and reduces
 Temp: 37.0 C mask, 6L/min; nebulization. lung volumes.
 PR: 136 bpm
 RR: 42 cpm  Monitored pulse oximetry, CXR.  Establishes baseline for monitoring
 BP: 100/70 mmHg progression/regression of disease process
and complications.
Pulse oximetry- can detect changes in
Oxygen saturation.

9. NURSING CARE PLAN
Identified Problem: deprivation from oxygen decreases the energy level
Nursing Diagnosis: Fatigue r/t poor physical condition secondary to generalized weakness due to hypoxic states
CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
Subjective: Short Term Objective: Independent: Short Term Objective:
“Hangak…” Within the 8 hours of  Recommended scheduling activities  Prevents overexertion, allows for some Outcome met:
“Naglisod ko ug ginhawa, nursing care, the patient for periods when the patient has activity within patient ability. The patient reported
kutas akong ginhawa.” as will report improve sense most energy. improve sense of energy
stated by the client. of energy as evidenced as evidenced by able to
“Kapoy man magsige ug by able to do activities in  Encouraged patient to do whatever  Provides for sense of control and feeling of do activities in an
lihok”, as verbalized by an acceptable level of what is possible. a accomplishment. acceptable level, and
patient. fatigue and report report in increase energy
increase energy level  Demonstrated proper performance  Protects patient from injury during activities. levels after providing
> Dyspnea/difficulty in after providing of ADLs, position changes. appropriate nursing care.
breathing appropriate nursing
intervention.  Encouraged nutritional intake/ use  Necessary to meet energy needs for
Objective: of supplements as appropriate. activity. Long Term Objective:
 Labored breathing Long Term Objective: Outcome met:
 Used of accessory muscle Within the 3-day of  Monitored breath sounds.  Hypoxemia and hypoxia increases sense of Within the 3-days of
 Hyperventilation nursing care, the client fatigue, impairs ability to function. nursing care, the client
 Changes in RR, depth and will be able to perform was able to perform
rate ADLs and participate in  Provided rest periods between  Conserves patient’s energy. ADLs and participated in
 Cyanotic/cool & clammy desired activities at level activities desired activities at level
skin of ability after providing of ability after providing
 Use of orthopneic position appropriate nursing and Collaborative: appropriate nursing and
 Apprehension collaborative  Provided supplemental oxygenation:  Provides increase in oxygenation thus collaborative
 Weak appearance interventions. partial rebreather mask, 6L/min; increases energy level. interventions.
 Drowsy nebulization.
 Unable to perform
activities  Evaluated need for individual  Aid in patient’s performance of certain
 Vital Signs: assistance/assistive devices. activities.
 Temp: 37.0 C
 PR: 136 bpm
 RR: 42 cpm
 BP: 100/70 mmHg

10. NURSING CARE PLAN
Identified Problem: Patient is unable to carry out routinely activities such as bathing, brushing, and etc. due to lack energy supply secondary decreased oxygen needs
Nursing Diagnosis: Self-Care Deficit (hygiene and self-toileting) r/t general weakness secondary to hypoxic state
CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
Subjective: Short Term Objective: Independent: Short Term Objective:
“Hangak…” as stated by the Within the 8 hours of  Assessed level of self-care abilities  Aids in planning for meeting individual Outcome met:
client. nursing care, the patient and deficits in performing ADLs. needs. After 8 hours of
“Maglisod man gyud ni siya and the SO will be able to nursing care, the patient
ug lihok-lihok kay naglisod identify and demonstrate  Provided devices and equipment that  Promotes performance of self-care and the SO was able to
siya ug ginhawa, ako na lang alternate ways to perform will aid the client in performing self- activities within client’s limitation. Also identify and demonstrate
siyang tabangan.” as stated self-care such as using care: promotes independence. alternate ways to
by SO. bedpan or commode, > glass of water and toothbrush perform self-care such
> Dyspnea/difficulty in having bed bath, and > bedpan or urinal for elimination as using bedpan or
breathing providing devices to >basin with water for hygiene commode, having bed
brush teeth on bed after bath, and providing
providing appropriate  Maintained a supportive, firm attitude.  Patients need empathy and to know and devices to brush teeth
Objective: nursing and collaborative Allowed patient sufficient time to to know caregivers will be consistent in on bed after providing
 Labored breathing interventions. accomplish tasks. their assistance. appropriate nursing and
 Used of accessory muscle collaborative
 Restlessness/confusion  Provided positive feedback for efforts  Enhances sense of self-worth, promotes interventions.
 Wide-eyed appearance and accomplishments. independence, and encourages patient to
 Hyperventilation continue endeavors.
 Inability to perform Long Term Objective: Long Term Objective:
activities such as bathing Within the 3-day nursing  Encouraged SO to allow patient to do  Reestablishes sense of independence Outcome met:
and tooth brushing care, the client will be as much as possible for self. and fosters self-worth and enhances After the 3-day
 Weakened state able to perform self-care rehabilitation process. nursing care, the client
 Unable to go to CR activities within the level was able to perform self-
 Vital Signs: of her own ability after Collaborative: care activities within the
 Temp: 37.0 C providing appropriate  Assisted or supported family with  Enhances likelihood of finding individually level of her own ability
 PR: 136 bpm nursing and collaborative alternative placements as necessary. appropriate situation to meet client’s after providing
 RR: 42 cpm interventions. needs. appropriate nursing and
 BP: 100/70 mmHg collaborative
interventions.