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Client in Context Present State Nursing Intervention Rationale Evaluation Patient History: Subjective Cues: Independent

The patient presented with severe shortness of breath, wheezing, and agitation due to asthma exacerbation. The nurse assessed the patient's vital signs, respiratory status, and oxygen saturation. Nursing interventions included positioning the patient upright, encouraging pursed-lip breathing, educating about triggers, and administering a nebulizer treatment per the physician's order. After 8 hours of nursing care, the patient was able to breathe easily and manifested normal respiratory signs, oxygen levels, and lung sounds.

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MelDred Cajes Bolando
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402 views3 pages

Client in Context Present State Nursing Intervention Rationale Evaluation Patient History: Subjective Cues: Independent

The patient presented with severe shortness of breath, wheezing, and agitation due to asthma exacerbation. The nurse assessed the patient's vital signs, respiratory status, and oxygen saturation. Nursing interventions included positioning the patient upright, encouraging pursed-lip breathing, educating about triggers, and administering a nebulizer treatment per the physician's order. After 8 hours of nursing care, the patient was able to breathe easily and manifested normal respiratory signs, oxygen levels, and lung sounds.

Uploaded by

MelDred Cajes Bolando
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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CLIENT IN PRESENT NURSING

RATIONALE EVALUATION
CONTEXT STATE INTERVENTION
Patient History: Subjective Independent:
-Patient came to Cues:  Assess the -Increased BP, RR, -Goal met. After 8
the ER -“Naglisud kog client’s vital and HR occur during hours of nursing
(Emergency ginhawa” as signs as needed the initial hypoxia intervention,
Room) with verbalized by while in distress. and hypercapnia. normal vital signs
severe shortness the patient. And when it becomes noted.
of breath, severe, BP and HR
wheezing, and Objective drops and respiratory
becoming more Cues: failure may result.
agitated. -severe
shortness of -Changes in the
History of breath noted  Assess the respiratory rate and -patient was able
Present Illness: -wheezing, and respiratory rate, rhythm may indicate to manifest normal
- Prior to a becoming more depth, and an early sign of respiratory rate,
check-up, patient agitated. rhythm. impending depth, and rhythm
complains - talking in words respiratory distress.
difficulty of -wheeze is
breathing audible -Get subjective data -patient was able
-uses accessory to determine if to manifest normal
History of muscles  Check pulse patient is receiving oxygen level.
Health: -restless, and oximetry. Apply proper amounts of
-The patient is shaky. oxygen if O2 oxygen.
known to be saturation is less
asthmatic since Vital signs are than 90%, start
childhood. She as follows: at 2 liters nasal
O
has a history of T= 35.9 C cannula (2L NC) -If wheezing they
depression and HR= 142 bpm may need a
had a history of RR= 36  Auscultate lung bronchodilator. -patient was able
admission to ICU breaths/min sounds If you hear crackles to manifest normal
2x. BP= 143/89 or rhonchi they may lung sounds
mmHg have pneumonia and
Socio- SpO2= 97% potentially could use
economic: suctioning.
-housewife
Key Issues: -Dust is near
Organ involved: -Ineffective impossible to
-Respiratory breathing completely get rid of,
system pattern related however, other -patient was able
to hypoxia as  Educate about triggers like pollen to determine about
evidence by triggers. Make (no flowers), animal their asthma
shortness of sure the dander (no visiting triggers and knows
breath with patient’s room puppies), etc. can be how to eliminate
activity, use of does not have eliminated. the trigger from
accessory any triggers their life.
muscles. -Opens lung bases
and airway

-patient was able


to breath easily
 Positioning
patient in an - Pursed lip breathing
upright position improves breathing
patterns by moving -patient was able
old air out of the to manifest
 Encourage client lungs and allowing improved
to use pursed-lip for new air to enter breathing pattern.
breathing for the lungs.
exhalation.

-To relief and


prevention of
bronchospasm in
patients with
Dependent: reversible obstructive -patient was able
airway. to manifest
 Administer improved
Ventolin breathing pattern
Nebulization as
ordered by the
physician

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