Asthma
Sample —for ideas only. Your own case → Create.
| Assessment data (subjective and objective findings relevant to THIS diagnosis) | Goals / expected outcomes | Nursing intervention | Rationale | Evaluation |
|---|---|---|---|---|
| Patient reports difficulty breathing and wheezing sounds heard on auscultation; possible use of accessory muscles and decreased air entry noted. | Patient will maintain adequate oxygenation as evidenced by normal respiratory rate, absence of wheezing, and SpO2 above 92% on room air. | Assess respiratory rate, depth, and effort every 1-2 hours. | Monitoring respiratory status helps detect early signs of worsening gas exchange and respiratory distress. | Respiratory parameters remain stable or improve with intervention. |
| Position patient in high Fowler’s position to maximize lung expansion. | Upright position facilitates easier breathing and improves ventilation. | Patient demonstrates easier breathing and reports decreased shortness of breath. | ||
| Encourage slow, deep breathing and use of pursed-lip breathing techniques. | Promotes effective ventilation and helps reduce air trapping and dyspnea. | Patient uses breathing techniques effectively and reports improved breathing comfort. | ||
| Administer supplemental oxygen as prescribed and monitor SpO2 continuously. | Oxygen therapy improves oxygen saturation and reduces hypoxia. | Oxygen saturation maintained within target range. | ||
| Monitor for signs of respiratory fatigue or increased work of breathing. | Early detection of respiratory failure allows timely intervention. | No signs of respiratory fatigue or deterioration observed. |
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