Asthma Nursing Care Plan & Management

Notes

image by: asthmakids.org.au

Definition
  • Asthma is a chronic inflammatory disease of the airways characterized by hyper-responsiveness, mucosal edema, and mucus production.
  • This inflammation ultimately leads to recurrent episodes of asthma symptoms: cough, chest tightness, wheezing, and dyspnea.
  • Patients with asthma may experience symptom-free periods alternating with acute exacerbations that last from minutes to hours or days.
  • Asthma, the most common chronic disease of childhood, can begin at any age.
Causes

The main triggers for asthma are allergies, viral infections, autonomic nervous system imbalances that can cause an increase in parasympathetic stimulation, medications, psychological factors, and exercise. Of asthmatic conditions in patients under 30 years old, 70% are caused by allergies. Three major indoor allergens are dust mites, cockroaches, and cats. In older patients,the cause is almost always nonallergic types of irritants such as smog. Heredity plays a part in about one-third of the cases.

Asthma

Pathophysiology

1. An asthma attack may occur spontaneously or in response to a trigger. Either way, the attack progresses in the following manner:

  • There is an initial release of inflammatory mediators from bronchial mast cells, epithelial cells, and macrophages, followed by activation of other inflammatory cells
  • Alteration of autonomic neural control of airway tone and epithelial integrity occur and the increased responsiveness in airways smooth muscle results in clinical manifestations (e.g. wheezing and dyspnea)

2. Three events contribute to clinical manifestations

  • Bronchial spasm
  • Inflammation and edema of the mucosa
  • Production of thick mucus, which results in increased airway resistance, premature closure of airways, hyperinflation, increased work of breathing, and impaired gas exchange

3. If not treated promptly, status asthmaticus – an acute, severe, prolonged asthma attack that is unresponsive to the usual treatment – may occur, requiring hospitalization.

Asthma Pathophysiology

Classification

1. Extrinsic Asthma – called Atopic/allergic asthma. An “allergen” or an “antigen” is a foreign particle which enters the body. Our immune system over-reacts to these often harmless items, forming “antibodies” which are normally used to attack viruses or bacteria. Mast cells release these antibodies as well as other chemicals to defend the body.

Common irritants:

  • Cockroach particles
  • Cat hair and saliva
  • Dog hair and saliva
  • House dust mites
  • Mold or yeast spores
  • Metabisulfite, used as a preservative in many beverages and some foods
  • Pollen

2. Intrinsic asthmacalled non-allergic asthma, is not allergy-related, in fact it is caused by anything except an allergy. It may be caused by inhalation of chemicals such as cigarette smoke or cleaning agents, taking aspirin, a chest infection, stress, laughter, exercise, cold air, food preservatives or a myriad of other factors.

  • Smoke
  • Exercise
  • Gas, wood, coal, and kerosene heating units
  • Natural gas, propane, or kerosene used as cooking fuel
  • Fumes
  • Smog
  • Viral respiratory infections
  • Wood smoke
  • Weather changes
 Clinical Manifestations
  • Most common symptoms of asthma are cough (with or without mucus production), dyspnea, and wheezing (first on expiration, then possibly during inspiration as well).
  • Asthma attacks frequently occur at night or in the early morning.
  • An asthma exacerbation is frequently preceded by increasing symptoms over days, but it may begin abruptly.
  • Chest tightness and dyspnea occur.
  • Expiration requires effort and becomes prolonged.
  • As exacerbation progresses, central cyanosis secondary to severe hypoxia may occur.
  • Additional symptoms, such as diaphoresis, tachycardia, and a widened pulse pressure, may occur.
  • Exercise-induced asthma: maximal symptoms during exercise, absence of nocturnal symptoms, and sometimes only a description of a “choking” sensation during exercise.
  • A severe, continuous reaction, status asthmaticus, may occur. It is life-threatening.
  • Eczema, rashes, and temporary edema are allergic reactions that may be noted with asthma.
Primary Nursing Diagnosis

Ineffective airway clearance related to obstruction from narrowed lumen and thick mucus

OUTCOMES
. Respiratory status: Gas exchange; Respiratory status: Ventilation; Symptom control behavior; Treatment behavior: Illness or injury; Comfort level
INTERVENTIONS. Airway management; Anxiety reduction; Oxygen therapy; Airway suctioning;Airway insertion and stabilization; Cough enhancement; Mechanical ventilation; Positioning;Respiratory monitoring

Assessment and Diagnostic Methods
  • Family, environment, and occupational history is essential.
  • During acute episodes, sputum and blood test, pulse oximetry, ABGs, hypocapnia and respiratory alkalosis, and pulmonary function (forced expiratory volume [FEV] and forced vital capacity [FVC] decreased) tests are performed.
  • Spirometry will detect:
    1. Decreased for expiratory volume (FEV)
    2. Decreased peak expiratory flow rate (PEFR)
    3. Diminished forced vital capacity (FVC)
    4. Diminished inspiratory capacity (IC)
Steps of Clinical and Diagnostic as per National Asthma Education and Prevention Program
Mild Intermittent Asthma
  • Symptoms ? 2 times per week
  • Brief exacerbations
  • Nighttime symptoms ? 2 times a month
  • Asymptomatic and normal PEF (peak expiratory flow) between exacerbations
  • PEF or FEV, (forced expiratory volume in 1 second) ? 80% of predicted value
  • PEF variability < 20%
Mild Persistent Asthma
  • Symptoms > 2 times/week, but less than once a day
  • Exacerbations may affect activity
  • Nighttimes symptoms > 2 times a month
  • PEF/FEV ? 80% of predicted value
  • PEF variability 20%-30%
Moderate Persistent Asthma
  • Daily Symptoms
  • Daily use of inhaled short-acting ?2 – agonists
  • Exacerbations affect activity
  • Exacerbations ? 2 times a week
  • Exacerbations may last  days
  • Nighttime symptoms > once a week
  • PEF/FEV > 60%-<80% of predicted value
  • PEF variability > 30%
Severe Persistent Asthma
  • Continual symptoms
  • Frequent exacerbations
  • Frequent nighttime symptoms
  • Limited physical activity
  • PEF or FEV ? 60% of predicted value
  • PEF variability > 30 %
Medical Management
Pharmacologic Therapy

There are two classes of medications—long-acting control and quick-relief medications—as well as combination products.

  • Short-acting beta2-adrenergic agonists
  • Anticholinergics
  • Corticosteroids: metered-dose inhaler (MDI)
  • Leukotriene modifiers inhibitors/antileukotrienes
  • Methylxanthines
Nursing Management

The immediate nursing care of patients with asthma depends on the severity of symptoms. The patient and family are often frightened and anxious because of the patient’s dyspnea. Therefore, a calm approach is an important aspect of care.

  • Assess the patient’s respiratory status by monitoring the severity of symptoms, breath sounds, peak flow, pulse oximetry, and vital signs.
  • Obtain a history of allergic reactions to medications before administering medications.
  • Identify medications the patient is currently taking.
  • Administer medications as prescribed and monitor the patient’s responses to those medications; medications may include an antibiotic if the patient has an underlying respiratory infection.
  • Administer fluids if the patient is dehydrated.
  • Assist with intubation procedure, if required.
Teaching Points
  • Teach patient and family about asthma (chronic inflammatory), purpose and action of medications, triggers to avoid and how to do so, and proper inhalation technique.
  • Instruct patient and family about peak-flow monitoring.
  • Teach patient how to implement an action plan and how and when to seek assistance.
  • Obtain current educational materials for the patient based on the patient’s diagnosis, causative factors, educational level, and cultural background.
Continuing Care
  • Emphasize adherence to prescribed therapy, preventive measures, and need for followup appointments.
  • Refer for home health nurse as indicated.
  • Home visit to assess for allergens may be indicated (with recurrent exacerbations).
  • Refer patient to community support groups.
  • Remind patients and families about the importance of health promotion strategies and recommended health screening.
Documentation Guidelines
  • Respiratory status: Patency of airway, auscultation of the lungs, presence or absence of adventitious breath sounds, respiratory rate and depth
  • Response to medications, oxygen therapy, hydration, bedrest
  • Presence of complications: Respiratory failure, ruptured bleb that may result in a pneumothorax

Exam

Welcome to your MSN Exam for Asthma Part 2! This exam is carefully curated to help you consolidate your knowledge and gain deeper understanding on the topic.

 

Exam Details

  • Number of Questions: 70 items
  • Mode: Practice Mode

Exam Instructions

  1. Practice Mode: This mode aims to facilitate effective learning and review.
  2. Instant Feedback: After each question, the correct answer along with an explanation will be revealed. This is to help you understand the reasoning behind the correct answer, helping to reinforce your learning.
  3. Time Limit: There is no time limit for this exam. Take your time to understand each question and the corresponding choices.

Tips For Success

  • Read each question carefully. Take your time and don't rush.
  • Understand the rationale behind each answer. This will not only help you during this exam, but also assist in reinforcing your learning.
  • Don't be discouraged by incorrect answers. Use them as an opportunity to learn and improve.
  • Take breaks if you need them. It's not a race, and your understanding is what's most important.
  • Keep a positive attitude and believe in your ability to succeed.

Remember, this exam is not just a test of your knowledge, but also an opportunity to enhance your understanding and skills. Enjoy the learning journey!

 

Click 'Start Exam' when you're ready to begin. Best of luck!

💡 Hint

Think about the doorway to a room. If one door is blocked, there's usually another you can use to get in. In this case, consider an agent that functions in a similar way to histamine, narrowing the doors—or rather, the airways.

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1. Jane, a pulmonologist, is preparing to perform a bronchoprovocation test on a patient to evaluate their airway responsiveness. While histamine is often used for this purpose, she is considering an alternative agent to challenge the airways. Which of the following could she potentially use instead of histamine?

💡 Hint

Imagine you're on a quest to find the source of a river. You'd naturally follow the water's flow, observing the surrounding vegetation and wildlife. But would the birds chirping in the distant forest guide you to the source? Not everything in the environment is a clue to your goal.

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2. Claire, a mother concerned about her daughter, is trying to understand the risk factors associated with the development of asthma. She's found several potential risk factors, but one of them isn't correct. Which one doesn't increase the risk of developing asthma?

💡 Hint

Picture a playground full of children. One child has just finished a speedy run around the park, panting heavily. This rapid breathing might be normal after such vigorous activity. However, if the child was just sitting and still breathing rapidly, we'd likely suspect something isn't quite right.

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3. Eman, a 7-year-old boy, is rushed to the emergency department. He's breathing rapidly (tachypneic) without a fever (afebrile), has a respiratory rate of 36 breaths per minute, and presents with a dry cough. He also had a cold recently. Considering these details, which of the following health conditions might Eman be experiencing?

💡 Hint

Imagine you're looking at a painting, and the artist has used a subtle color change to indicate a crucial detail. It's similar when you're looking for cyanosis in a patient with dark skin - some areas of the body can reveal color changes more clearly than others.

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4. Late one evening, the emergency department where you're working as a nurse gets busy. A patient with asthma, Mr. Johnson, walks in, experiencing severe respiratory distress. Given Mr. Johnson's darker skin tone, evaluating cyanosis becomes slightly tricky.

Where should you as a nurse focus your assessment for cyanosis considering Mr. Johnson's dark skin?

💡 Hint

Think about a wildfire. It could be caused by a single spark, or a combination of dry conditions, high winds, and accumulated fuel. Similarly, in the intricate workings of our body, a combination of factors often conspire to create a problem.

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5. George, a middle-aged man with asthma, is trying to understand what triggers his asthma attacks. He knows it's vital to avoid these triggers to manage his condition better. Which of the following could potentially provoke an asthma attack?

💡 Hint

When describing asthma, imagine a garden hose. If the water pressure suddenly drops or the hose kinks, the flow of water is restricted. Now consider which of the given options doesn't quite fit this picture.

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6. Nathan, a nursing student, is preparing for an exam on respiratory disorders and is studying asthma. He's trying to identify the defining features of this condition. However, one of the following isn't a characteristic of asthma. Which one is it?

💡 Hint

Picture yourself in the scenario. The patient is brought in, struggling for breath with a high fever and difficulty swallowing. These are classic signs of a respiratory condition that blocks the windpipe, leading to a potentially life-threatening situation. It's a condition that primarily affects children but can also occur in adults, and rapid diagnosis and treatment are essential to prevent serious complications.

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7. In the middle of a bustling hospital, a patient suddenly arrives at the emergency department, showing severe signs of a respiratory issue. As a nurse, you need to identify the situation quickly. Given the following respiratory disorders, which one would you unequivocally recognize as a medical emergency, demanding immediate intervention?

💡 Hint

Ever find it challenging to finish your favorite spicy dish late at night? Remember how it could sometimes keep you up? It's worth noting that the body's digestive processes don't clock out when we do, and certain conditions can become more apparent during restful periods.

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8. Marianne is a long-term asthma patient. Despite religiously adhering to her prescribed medication regimen, she continues to experience persistent symptoms. These symptoms are notably worse at night, leading to frequent sleep disruptions. Given these circumstances, would you think about gastroesophageal reflux disease (GERD) as a potential contributing factor to her poorly managed asthma?

💡 Hint

Picture a congested highway with bumper-to-bumper traffic. What would help clear this up? You would want something that can widen the lanes and make more room for vehicles to pass. Apply this logic to our airways during an asthma attack.

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9. Austin, a patient experiencing an acute asthma attack, is presenting with wheezing during both inhalation and exhalation, along with a reduced forced expiratory volume. As his healthcare provider, which category of medication should you administer immediately to manage his symptoms?

💡 Hint

If you've ever had a seasonal allergy, you know how pollen can make you sneeze or itch. It's not just a nuisance; for some, it might also make breathing a tough task.

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10. Peter, an asthmatic, is attending a friend's outdoor garden party. He loves pets and his friend's dog is running around the garden. As the pollen from the garden's plants fills the air, he also strokes the furry dog. Could such allergens as pollen and animal fur trigger his asthma?

💡 Hint

Take a moment to think about traffic lights. Green signifies go, yellow warns us to prepare, and red instructs us to stop. Similarly, a peak flow meter uses these color codes to help individuals with asthma manage their condition. As their respiratory status shifts, so does their response - just like adapting to the changing traffic signals while driving.

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11. In the bustling heart of a city hospital, Nurse Maya diligently educates a patient with asthma about the proper use of a peak flow meter. This small but powerful device can be a lifeline in managing her condition, alerting her to changes in her respiratory status and guiding her actions. What will be a clear sign that the patient has fully understood Nurse Maya's instruction?

💡 Hint

Imagine a pipe with its inner lining swollen and inflamed, restricting the passage of air. What would you hear as air tries to squeeze through this narrowed passage?

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12. A child has been rushed to the emergency room experiencing an asthma attack. As the attending nurse, what symptoms and signs should you anticipate in this situation?

💡 Hint

Let's say, a patient with an elevated heart rate might get a certain medication that won't leave them gasping for breath.

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13. Nurse Ava is preparing medication for her patient who has a history of asthma. She remembers that some medications can potentially trigger asthma symptoms and is double-checking her patient's prescription. Which of the following medications is not associated with causing asthma?

💡 Hint

Asthma is often seen as a common, manageable condition, which it usually is with appropriate care. However, under certain circumstances, it can escalate into a severe episode known as "status asthmaticus." This is a situation where traditional rescue medications fail to alleviate symptoms, and immediate medical intervention becomes essential. Even though it's a relatively rare scenario, it underscores the gravity of this seemingly commonplace condition.

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14. Late one chilly night, emergency room nurse Clara finds herself rushing to attend to young Oliver, a 7-year-old boy battling an intense asthma attack. His labored breathing sends a stark reminder of a critical fact about the condition he's struggling against. Does it hold the potential to be life-threatening?

💡 Hint

Picture the long-standing nature of persistent asthma and what continuous presence in the airways could contribute to this unrelenting state.

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15. As a health professional, you are discussing the distinct features of different types of asthma with your peers. When it comes to persistent asthma, what would you say is its characteristic feature?

💡 Hint

When assessing for reversibility, you're primarily interested in a parameter that reflects the volume of air that can be forcibly exhaled in a specified time frame after taking a deep breath, typically in the first second. This measurement often proves critical in evaluating conditions like asthma or COPD, where the airway obstruction could potentially be reversible.

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16. You're a nurse performing a spirometry test on a patient to evaluate their lung function. You're specifically interested in assessing the reversibility in airflow obstruction. Which of the following parameters would you primarily rely on for this determination?

💡 Hint

Remember, asthma is a widespread issue with significant effects on the health, school attendance, and hospitalization rates of children across the nation.

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17. As a health educator, you are preparing a presentation about asthma for a school community. You plan to include a statement about the impact of asthma on children nationwide. Which of the following statements is accurate?

💡 Hint

Think of a time when most people are deeply asleep, lost in their dreams, oblivious to the world around them.

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18. Elizabeth, a patient suffering from nocturnal asthma, is trying to understand the pattern of her symptoms better. She's uncertain about the typical time frame during which nocturnal asthma occurs. When does nocturnal asthma typically manifest?

💡 Hint

Asthma's primary characteristics involve changes in the respiratory system that affect the flow of air. Its symptoms often manifest as a direct result of these changes, typically causing difficulties in breathing. Picture what happens to the bronchial tubes during an asthma attack, and you'll likely find the correct answer.

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19. A patient comes to you, displaying certain signs and symptoms, and you suspect they might have asthma. Which of the following would you consider as a genuine symptom indicative of this respiratory condition?

💡 Hint

Think of the fundamental goals of asthma treatment - to open the airways and to reduce inflammation.

20 / 70

20. Liam, a newly diagnosed asthmatic, is having a conversation with his healthcare provider about his treatment options. They discuss the two main categories of medications used to manage asthma. What are these two categories?

💡 Hint

Consider a crowded marketplace. When too many people try to move through a narrow alley, movement becomes challenging. This analogy isn't too far off when understanding the dynamics of airflow in certain lung conditions.

21 / 70

21. Sam, a curious teenager, is researching asthma for a school project. He comes across a statement claiming that asthma is caused by inflammation of the airways in the lungs. Is this statement accurate?

💡 Hint

Asthma management often requires a comprehensive approach, including environment control measures to reduce exposure to triggers. Remember, dust mites thrive in various locations and items, so a multi-pronged strategy is often necessary for effective control.

22 / 70

22. You're advising a patient with asthma on how to minimize potential triggers in their environment. Dust and dust mites are known to exacerbate their symptoms. Which of the following recommendations would you provide to reduce their exposure and thus lower the chances of an asthma flare-up?

💡 Hint

Picture a scale weighing up different aspects of our health. While all of them contribute to the overall picture, some factors can tip the balance more significantly, especially when we're considering something as serious as a stroke.

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23. Susan, a Caucasian woman with a history of bronchial asthma, exogenous obesity, and iron deficiency anemia, has been admitted to the hospital following a stroke (cerebrovascular accident or CVA). Looking at Susan's medical history, which aspect could have increased her risk for a CVA?

💡 Hint

Imagine how an artist might feel if they were told to stop painting because of a newly diagnosed allergy to a certain paint type. Wouldn't it make more sense to find a way to continue doing what they love, while minimizing risk?

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24. Tommy, a seven-year-old boy, has recently been diagnosed with asthma. His family is trying to adapt to this new situation and make the necessary changes for Tommy's well-being. However, one of their statements about managing Tommy's asthma suggests they might benefit from further education. Which statement is that?

💡 Hint

Imagine you are planning a picnic. You would choose foods that are both enjoyable and easy to eat, wouldn't you? Apply this concept to a toddler's snack, bearing in mind the impact certain foods can have on breathing.

25 / 70

25. Two-year-old Lily, who has recently been diagnosed with acute asthma, is under your care as a nurse. You're planning a healthy snack for her. Considering her condition, which of the following would be the best snack option for her?

💡 Hint

When you think of COPD, recall that it primarily involves conditions that cause obstruction to the airflow within the bronchial tubes due to changes in the airways and/or damage to the lung tissue. The term "hypotension" usually refers to blood pressure, not airway pressure. So the disease with "hypotension" in its name may not fit with the others.

26 / 70

26. In the midst of a medical discussion, you, a knowledgeable nurse, are asked about chronic obstructive pulmonary disease (COPD) and its associated conditions. Among the options given, which one would you not categorize as a disease related to COPD?

💡 Hint

To lead you down the right path, imagine the test involves a patient with a potential asthma diagnosis. The chosen bronchodilator should be one that's commonly used for immediate relief of asthma symptoms due to its quick action in relaxing the muscles of the airways and widening the bronchial passages, effectively demonstrating the reversibility of airflow obstruction.

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27. In the midst of an ongoing evaluation in the pulmonology department, a nurse is asked to perform a reversibility test. The intent is to understand the patient's lung function better and measure the extent of bronchodilation that can be achieved. Among the options below, which bronchodilator would you primarily use in this scenario?

💡 Hint

There's a word in the medical world for an overreaction to harmless substances, such as pollen, that the body deems as foreign. This misdirected response often leaves people sneezing or coughing, and for some, like Matthew, even wheezing. Take a moment to consider the nuances of the body's defense mechanism against perceived threats and its relation to the seasonal nature of Matthew's asthma.

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28. In the heart of spring, Amelia, a recently graduated nurse, found herself faced with a case that puzzled her. She was treating Matthew, a young boy, who every year, like clockwork, would develop asthmatic symptoms only during the season of blossoms. Amelia wondered, "What could be triggering Matthew's seasonal asthma?"

💡 Hint

Consider the concept of "third-hand smoke" - the residual nicotine and other chemicals left on a variety of indoor surfaces by tobacco smoke. These chemicals can linger long after the smoking has stopped.

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29. As part of a health awareness program at a school, there's a discussion about how personal habits of the staff could impact students with asthma. One point of discussion is whether staff who smoke during their personal time could potentially harm children with asthma. Is this statement accurate?

💡 Hint

As you go about the procedure, remember the primary purpose of percussion in a physical examination. You are assessing the air-filled structures, mainly the lungs, in the patient's thoracic cavity. Your knowledge of normal pulmonary function and the basic principles of sound can lead you to the correct answer.

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30. Imagine a woman with a slight weight problem, a background of allergy-triggered asthma, high blood pressure, and an issue with her mitral valve, presenting herself for a planned surgical procedure in a hospital. As a nurse, you meticulously collect her health history and perform an exhaustive physical examination, focusing particularly on her heart and lung systems. During the percussion of the patient's chest wall, what kind of sound would you anticipate to hear?

💡 Hint

Consider the strong aroma that fills the air when you spray a perfume or use a powerful cleaning product. It's more than just a smell; it's a cloud of tiny particles that you breathe into your lungs.

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31. James, an individual with asthma, is curious about potential triggers for his condition. He comes across a claim that fragrant substances like perfumes and cleaning products can set off an asthma attack. Is this claim accurate?

💡 Hint

Pay attention to the drumbeat. The rhythm of the heart can speak volumes about the body's condition. It might be trying to keep up with an increased demand, or it might be responding to a disruptive influence.

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32. Anna Smith, a patient with asthma, is currently being treated with bronchodilators. As her nurse, you have to vigilantly monitor certain side effects related to the medication she's taking. Which of the following sets of symptoms should you be particularly attentive to?

💡 Hint

This condition's name comes from the Greek word meaning "panting." The intermittent nature of symptoms differentiates it from other chronic respiratory conditions, often making it an unwelcome surprise for those who experience it. Though it can be triggered by various factors, it often involves an immune response that leads to inflammation and swelling within the airways.

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33. In the midst of a bustling emergency room, a nurse tends to Samantha, a middle-aged woman who's been experiencing sporadic bouts of shortness of breath, a tight chest, and intermittent coughing. She's particularly concerned about her wheezing - a novel symptom she hasn't experienced before. From a healthcare perspective, these symptoms suggest a condition that may be:

💡 Hint

In the realm of respiratory diagnosis, it's vital to remember that some tests act like windows, letting you peek into the body's hidden spaces, while others act more like yardsticks, measuring function rather than peering into form. The key here lies in distinguishing between functional evaluations of the lungs and those that delve deeper, seeking physical traces of inflammation.

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34. In the peaceful quietude of the hospital lab, technician Mike is readying a series of tests for John, a patient presenting with a persistent cough and wheezing. A host of diagnostic procedures lie ahead, each designed to probe for a different aspect of his condition. Which among the following tests, however, won't be able to reveal any inflammation in John's airways?

💡 Hint

Think of asthma as a complex symphony of changes occurring within the respiratory airways. It isn't simply a single-note phenomenon; instead, it orchestrates a range of responses. The hallmarks of this condition span inflammation, mucus production, and bronchoconstriction. All these changes play their part in the symphony, creating the unique sound—or rather, the characteristic symptoms—of asthma.

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35. At a local healthcare clinic, Dr. Amelia studies the charts of a newly diagnosed asthma patient. Through the stethoscope, the telltale signs of the condition whisper clearly into her ears: the wheezing, the struggle of breath against the obstruction. She ponders over the implications of this disease for the patient's airways. Does asthma cause them to:

💡 Hint

A playful hop, skip, and wheeze might not seem as unusual in a certain lively demographic, especially when inhalers seem to be just as common as lollipops.

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36. In the bustling pediatric ward, Nurse Ben finds himself frequently treating a certain health issue. Out of curiosity, he decides to look up the prevalence of this condition in various age groups. In which demographic is asthma most commonly diagnosed?

💡 Hint

The sneeze when you enter a dusty room or the teary eyes in a blossoming garden, these aren't signs of a flu but reactions to specific triggers. However, a battle with the common cold doesn't usually leave the same mark.

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37. Let's consider a teenager, Alex, who's been recently diagnosed with allergic asthma. Certain symptoms and triggers align with his diagnosis, but one of the following statements doesn't accurately characterize his allergic asthma. Which one is it?

💡 Hint

Picture a pebble in your shoe. It might cause you discomfort over a long walk. Now, imagine a foreign object lodged in a less accessible place, like your airways. Time doesn't always resolve such issues.

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38. Benjamin, a patient who has been experiencing persistent coughing and wheezing for over a year, comes to see you. Given the length of time that Benjamin has been exhibiting these symptoms, would you completely discount the possibility of a foreign object lodged in his airway?

💡 Hint

It's vital to understand that while some individuals with asthma may be sensitive to certain triggers, such as animal dander, others might not have the same reactions. Hence, a 'one-size-fits-all' approach might not be the most efficient strategy.

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39. In a parent-teacher meeting at a local school, a proposal is put forward to ban all classroom pets to prevent asthma triggers among the students. Is this a necessary action to prevent potential asthma triggers?

💡 Hint

When considering vaccination, it's crucial to recognize that a particular condition could make a person more susceptible to adverse effects or complications. In this context, the child's ability to mount an adequate immune response is crucial for the vaccine to work effectively and safely. If something is already compromising this ability, it could be a significant cause for concern.

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40. You're a pediatric nurse, and a young patient comes in for a routine immunization. Prior to administering the vaccine, you're aware that certain conditions could pose a risk. Which of the following circumstances would you be most concerned about before giving the child the immunization?

💡 Hint

The airways in our lungs can be sensitive to various triggers, which may cause them to constrict, inflame, or produce excess mucus, leading to specific observable symptoms. Asthma is one such condition that reflects this response in the respiratory system. Keep in mind how children, like Teddy, might exhibit these symptoms.

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41. It's a typical weekday at your nursing station when the school calls regarding a 9-year-old boy, Teddy, who they believe might be showing signs of a health issue. They provide the following list of symptoms that Teddy has been exhibiting: persistent coughing, audibly wheezing when exhaling, a feeling of constriction in his chest, labored breathing, and restless sleep due to breathlessness.

💡 Hint

When administered at recommended doses, most medications are engineered to optimize therapeutic effects while minimizing adverse reactions. In the case of inhaled steroids for asthma management, the key lies in the direct delivery mechanism which helps to limit systemic exposure and therefore potential side effects. Health and medication, it seems, often come with a delicate balancing act.

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42. As a nurse, you are counseling a patient who has just been diagnosed with asthma. The patient expresses concerns about starting a course of inhaled steroids as a preventer or controller due to fear of significant side effects. The prescribed dosages fall within the standard recommendation. How would you address this worry?

💡 Hint

During a severe asthma attack, the struggle for air can be so intense that it can lead to a specific emergency situation. This situation involves the presence of air where it shouldn't be, creating a pressure imbalance that could potentially impede the very act of breathing. Remember, an X-ray can act as a window, revealing what the naked eye can't see, including air lurking in unwanted spaces.

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43. Emma, an experienced nurse, was called into the emergency department to assist in managing Jacob, a young adult experiencing a severe, acute asthma attack. While helping stabilize Jacob, Emma knew that some diagnostic measures were crucial to rule out other potential issues during such a severe episode. She reflected on the essential need for a chest x-ray to exclude:

💡 Hint

Think about how our bodies react when we experience strong emotions. We often forget that emotions are not just mental or psychological; they also cause physical reactions.

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44. Emma, an individual with asthma, has noticed that strong emotional reactions such as crying, laughing hard, or yelling sometimes make her feel short of breath. Could these emotional responses trigger her asthma?

💡 Hint

In the fascinating world of nursing, tools are not always used for their conventional purposes. Sometimes, a simple device can offer a glimpse into a complex system, such as the lungs. The tool in question is commonly employed by people with conditions like asthma, allowing them to monitor their breathing capacity and adjust their medication if necessary.

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45. In a bustling community health center, Nurse Jamie needed a basic tool to roughly gauge the lung function of Mr. Sullivan, an older patient with a history of respiratory issues. Which instrument would Nurse Jamie likely utilize?

💡 Hint

Think about what you've seen and heard about asthma. Its symptoms clearly disrupt breathing, it's not short-lived, and it certainly can't be classified as minor. Remember, it involves the airways and has a chronic character, often requiring long-term management.

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46. You're in a health education session, where a curious patient asks you to explain a certain condition that involves recurrent episodes of wheezing, coughing, chest tightness, and shortness of breath. How would you best describe asthma?

💡 Hint

As Jane details each potential side effect, she thoughtfully takes a sip of her herbal tea. "Funny thing," she muses, "I have this tea to help keep my mouth healthy and fight off fungi. Though I must say, it's a good thing your prescribed medication doesn't call for such an unusual routine."

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47. In the small but bustling neighborhood pharmacy, pharmacist Jane is counseling a middle-aged man recently prescribed a bronchodilator for his asthma symptoms. As she outlines the possible side effects of the medication, she emphasizes that one of the following is not typically associated with bronchodilator use:

💡 Hint

The cornerstone of assessing asthma control in a child revolves around the frequency of symptom flare-ups and the use of rescue medications. Remember, a well-managed asthma patient should have infrequent need for these 'rescue' interventions. The number of prescription refills often offers a practical and real-world assessment of this critical aspect of asthma management.

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48. In a cozy corner of the pediatric clinic, nurse Miranda sits across from a concerned mother whose 8-year-old son has asthma. With a hint of apprehension in her voice, the mother inquires about the effectiveness of her son's ongoing treatment. To ensure an accurate response, Miranda considers the need to:

💡 Hint

When we think about asthma, it's important to note that our bronchial tubes, akin to the leaves of a tree, have muscular walls. During an asthmatic attack, these muscular walls react more strongly to certain stimuli, leading to an episode of wheezing, breathlessness, or a tight chest, akin to a tree's leaves curling in on themselves during a storm.

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49. During one of your nursing shifts, you encounter a young patient, Maddie, a seven-year-old girl who is a frequent visitor to the hospital due to her ongoing battle with asthma. Maddie's condition got you thinking about the fundamental biological changes that occur in the body during the onset of this respiratory disorder.

In this context, which of the following options best describes the main physiological alteration in the progression of asthma?

💡 Hint

When you're orchestrating a symphony of care for a patient with an acute asthma exacerbation, wouldn't you want your initial steps to create immediate, beneficial changes in their breathing patterns? Consider the role of a conductor who, with the wave of their baton, can control the tempo and dynamics of the orchestra. Similarly, the right initial treatment can be instrumental in achieving a harmonious respiratory rhythm.

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50. The on-call nurse, Laura, has just received a new patient, a ten-year-old boy with severe asthma. He's wheezing, his breaths are rapid, and his oxygen levels are dropping. Laura has seen acute asthma exacerbations before but this one looks serious. In this case, she needs to recall the most crucial information from her recent training about handling such conditions. What would that key piece of knowledge be?

💡 Hint

Imagine a sailor gauging a storm. The color of the sky, the height of the waves, the speed of the wind - these all help measure the storm's intensity. But would the sailor care about the number of fish around the boat? Not every observation is relevant to every situation.

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51. You are a nurse and have just admitted Emma, a 10-year-old girl, to the emergency room due to a sudden asthma attack. To gauge the severity of her condition, you plan to assess various factors. However, one of the following is not useful in determining the severity of Emma's acute asthma attack. Which one is it?

💡 Hint

Imagine listening to a musical instrument, like a flute or a guitar. A change in pitch can dramatically alter the sound and the mood of the piece. Similarly, in a clinical scenario, changes in the pitch of respiratory sounds can provide significant clues about the condition of a patient's airways, revealing whether the obstruction has decreased or increased.

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52. As a dedicated nurse on duty, you're carefully monitoring the condition of Mr. Kim, an asthmatic patient. Initially, you noted low-pitched wheezes in the latter half of his exhalation. However, an hour later, you observe high-pitched wheezes throughout the entire exhalation.

Given this change in Mr. Kim's condition, what does it suggest to you as a nurse?

💡 Hint

Think of the great outdoors - the shifting weather, the blooming flowers, and the invisible particles in the air we breathe.

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53. Max, a young boy with asthma, loves outdoor activities but is concerned about possible triggers. He's trying to understand common outdoor triggers for asthma. Which of the following best describes common outdoor asthma triggers?

💡 Hint

Consider the period of adolescence and early adulthood, a time when bodies are undergoing a multitude of changes and transitions.

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54. Jane, a health researcher, is analyzing the prevalence of asthma across different age and gender groups. She finds that two particular groups have the highest rates of asthma. Which two population groups have the greatest prevalence of asthma?

💡 Hint

When you consider asthma, it helps to remember the hallmark signs and triggers, such as allergies and environmental factors. These considerations will guide you to the true essence of this chronic respiratory disease, involving hyperactive airways and inflammation.

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55. A patient with frequent bouts of wheezing, shortness of breath, and tightness in their chest coming to you, a healthcare provider, for assistance. You identify these symptoms as being characteristic of a particular respiratory condition. Which of the following best describes the fundamental nature of asthma?

💡 Hint

Remember, the journey of asthma management is one of adherence and discipline, not overindulgence or disregard. It's not only about the medication you take but also about the way you take it. Consistent, appropriate use of prescribed medication is like the steady hand on the tiller that keeps the ship on course, even in stormy seas of unpredictable asthma flares.

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56. Late in the evening, Susan, a dedicated nurse, meets her neighbor Linda in their apartment complex. Linda, who has been diagnosed with asthma, anxiously asks for advice on managing her condition. Pondering the best advice, Susan thinks of the following actions. Which one should Linda adopt for her asthma management?

💡 Hint

Imagine if every time you walked into a bakery, you ended up with a stomach ache. You would want to know that it was the bakery causing this reaction, right? Understanding the triggers of certain conditions can empower us to manage them better.

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57. Jessa, a young girl recently diagnosed with asthma, is ready for discharge from the hospital after recovering from a severe episode of status asthmaticus. As part of the discharge process, Jessa and her family need to receive specific education. Which of the following points should this teaching emphasize?

💡 Hint

Remember, a key factor to consider in classifying asthma is the frequency of both daytime and nocturnal symptoms. It's worth noting that nocturnal awakening, even if it's happening 2-3 times per week, is a significant factor. It indicates the disease may be having a larger impact on the patient's life than might be initially perceived.

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58. A 5-year-old African American boy with a history of asthma visits your clinic. He's not currently on any regular medication but uses his Albuterol Metered Dose Inhaler (MDI) with a spacer once every two weeks during daytime. Additionally, he wakes up coughing 2-3 times per week at night. Based on these details, how would you classify his asthma?

💡 Hint

The silent chest can be more than it appears. While it might initially seem like a relief, when it comes to respiratory conditions, silence is not always golden. It may indeed indicate a deepening crisis where airflow is obstructed to a critical level.

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59. During a hectic shift at the hospital, Nurse Emma was tending to Kenneth, a patient in the midst of a severe asthma attack. Suddenly, Kenneth's wheezing ceased and his breath sounds become inaudible. What might be the reason behind this startling development?

💡 Hint

Asthma orchestrates an unwelcome concert within the airways, involving inflammation, hyper-responsiveness, and intermittent obstruction. Its symptoms aren't just about the breath, but also about the passages through which the breath flows. As a chronic inflammatory disorder, it plays out its main act along the inner lining of the airways, leading to sensitivity and swelling among other features.

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60. In the calm of her office at the local clinic, family nurse practitioner Rachel prepares for her next appointment. She glances at the file of a new patient, Emma, whose medical history indicates asthma. Anticipating the array of symptoms Emma might present, Rachel considers the likelihood of:

💡 Hint

Consider how many successful athletes have managed their conditions and still performed at the top of their game. From runners to swimmers, their success is often contingent on a combination of determination, well-managed health conditions, and a disciplined training regime.

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61. Liam, an active teenager with a passion for soccer, has recently been diagnosed with asthma. He's worried that his diagnosis might mean the end of his sports pursuits. Is it accurate to say that having asthma prevents participation in physical activities?

💡 Hint

Consider what we breathe in every day and the sources of nourishment in our early lives. It's often the most basic elements of our living environment that have the most profound impact on our health.

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62. As a public health official, Alice is planning a campaign focused on primary prevention of asthma. She has been researching the crucial factors that could help prevent asthma onset. Which of the following options correctly describes these factors?

💡 Hint

Consider a fire extinguisher versus a smoke alarm. One alerts you to potential danger while the other is used to handle the immediate crisis.

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63. Emily, newly diagnosed with asthma, is learning about her medications. She's trying to distinguish between a 'preventer' and a 'reliever' in the context of asthma management. Which of the following statements correctly represents the role of these medications?

💡 Hint

Consider the immediacy of the situation. Your priority is to alleviate the acute respiratory distress, which is life-threatening. The best course of action in such a case often involves medication that can quickly open up the patient's airways and restore normal breathing.

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64. You are in the Emergency Department when a 19-year-old patient arrives, showing signs of an acute asthma attack. His breaths are coming in at a rapid rate of 44 per minute, and it's evident he's in severe respiratory distress. What is the immediate step you should take in managing this patient?

💡 Hint

There are several common triggers that can cause an asthma attack. Unconventionally, certain allergens present in our everyday surroundings, such as dust mites and even cockroaches, can potentially provoke these episodes. You might be surprised by what might be lurking in the corners affecting our respiratory health.

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65. As a nurse in a busy urban clinic, you are addressing a patient who complains of frequent asthma attacks at home. Upon inquiry, she mentions a recent cockroach infestation. She wonders if the presence of these insects could possibly aggravate her condition.

💡 Hint

Think about a traffic jam scenario. What would you see and hear? Horns honking, maybe? Tires screeching as cars struggle to move? People expressing their frustration? When things aren't flowing smoothly, certain signs make the problem evident.

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66. Liza's close friend, Robert, has recently been diagnosed with asthma. She's been reading up about the condition to better understand what Robert is experiencing. She believes that symptoms of asthma include wheezing, coughing, and difficulty in breathing. Is Liza's understanding correct?

💡 Hint

Think about a well-crafted musical instrument, such as a trumpet. It's not just about the quality of the instrument, but also the skill of the player that creates the beautiful sound. Similarly, the efficacy of some tools is highly dependent on how they are used.

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67. Greg, a newly diagnosed asthmatic, is learning to use his inhaler. He wonders if mastering the correct inhalation technique will ensure that the medication reaches his lung airways effectively. Is Greg's assumption correct?

💡 Hint

Asthma is a complex condition influenced by a variety of factors including genetics, environment, and individual health history. Despite advancements in managing the symptoms, we're yet to completely outwit this disease.

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68. Olivia, recently diagnosed with asthma, is researching her condition. She reads a statement that says there's no singular cause for asthma and, as of now, there is no cure for the disease. Is this statement accurate?

💡 Hint

Ponder about the history of the child's asthma management. Specifically, think about the severity of asthma that requires regular usage of a certain class of medication to keep symptoms under control.

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69. You are a nurse caring for a hospitalized 6-year-old child. Which piece of information would raise your concern that this child could potentially face a severe exacerbation of asthma?

💡 Hint

As a physiotherapist, Sam's role isn't confined to just one aspect of patient care. His contributions extend to various areas, all aimed at enhancing the overall wellbeing of his patients. Think about the holistic approach that physiotherapy entails, as it integrates physical, educational, and psychological aspects in the management of health conditions such as asthma.

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70. Sam, a seasoned physiotherapist, had a new client, Jasmine, who had recently been diagnosed with asthma. Now, Sam needed to determine the vital part he would play in her asthma management. What was his key responsibility?

Nursing Care Plan

Ineffective Airway Clearance
Assessment

Patient may manifest

  • Difficulty breathing
  • Changes in depth and rate of respiration
  • Use of respiratory accessory muscles
  • Persistent ineffective cough with or without sputum production
  • Wheezing upon inspiration and expiration
  • Dyspnea
  • Coughing
  • Tachypnea, prolonged expiration
  • Tachycardia
  • Chest tightness
  • Suprasternal retraction
  • Restlessness
  • Anxiety
  • Cyanosis
  • Loss of consciousness
Nursing Diagnosis
  • Ineffective airway clearance RT bronchoconstriction, increased mucus production, and respiratory infection AEB wheezing, dyspnea,  and cough

May be related to

  • Increased production or retainment of pulmonary secretions
  • Bronchospasms
  • Decreased energy
  • Fatigue
Planning
  • Patient will maintain/improve airway clearance AEB absence of signs of respiratory distress
  • Patient will verbalize understanding that allergens like dust, fumes, animal dander, pollen, and extremes of temperature and humidity are irritants or factors that can contribute to ineffective airway clearance and should be avoided.
  • Patient will demonstrate behaviors that would prevent the recurrence of the problem.
Nursing Interventions
  • Keep the patient adequately hydrated.
    • Rationale: Systemic hydration keeps secretion moist and easier to expectorate.
  • Teach and encourage the use of diaphragmatic breathing and coughing exercises.
    • Rationale: These techniques help to improve ventilation and mobilize secretions without causing breathlessness and fatigue.
  • Instruct patient to avoid bronchial irritants such as cigarette smoke, aerosols, extremes of temperature, and fumes.
    • Rationale: Bronchial irritants cause bronchoconstriction and increased mucus production, which then interfere with airway clearance.
  • Teach early signs of infection that are to be reported to the clinician immediately.
    • Rationale: Minor respiratory infections that are of no consequence to the person with normal lungs can produce fatal disturbances in the lungs of an asthmatic person. Early recognition is crucial.
  • Assist and prepare patient for postural drainage.
    • Rationale: Uses gravity to help raise secretions so they can be more easily expectorated.
  • Administer nebulization as ordered.
    • Rationale: This ensures adequate delivery of medications to the airways.
  • Administer medications as ordered.
    • Rationale: Antibiotics may be prescribed to treat the infection.

Ineffective Breathing Pattern
Assessment

Patient may manifest: 

  • wheezing upon inspiration and expiration
  • dyspnea
  • coughing
  • tachypnea
  • tachycardia
  • chest tightness
  • suprasternal retraction
  • restlessness
  • anxiety
  • cyanosis
  • loss of consciousness
Nursing Diagnosis
  • Ineffective breathing pattern r/t presence of secretions AEB productive cough and dyspnea
Planning
  • Patient will demonstrate pursed-lip breathing and diaphragmatic breathing.
  • Patient will manifest signs of decreased respiratory effort AEB absence of dyspnea
  • Patient will verbalize understanding of causative factors and demonstrate behaviors that would improve breathing pattern
Nursing Interventions
  • Assess patient’s respiratory rate, depth, and rhythm. Obtain pulse oximetry.
    • Rationale: To obtain baseline data
  • Monitor and record vital signs.
    • Rationale:Increase in respiratory rate could mean worsening condition.
  • Auscultate breath sounds and assess airway pattern
    • Rationale: to check for the presence of adventitious breath sounds
  • Elevate head of the bed and change position of the pt. every 2 hours.
    • Rationale: To  minimize difficulty in breathing
  • Encourage deep breathing and coughing exercises.
    • Rationale: To maximize effort for expectoration.
  • Demonstrate diaphragmatic and pursed-lip breathing.
    • Rationale: To decrease air trapping and for efficient breathing.
  • Encourage increase in fluid intake
    • Rationale: To prevent fatigue.
  • Encourage opportunities for rest and limit physical activities.
    • Rationale: To prevent situations that will aggravate the condition
  • Reinforce low salt, low fat diet as ordered.
    • Rationale: To mobilize secretions.

Impaired Gas Exchange
Assessment

Patient may manifest: 

  • wheezing upon inspiration and expiration
  • dyspnea
  • coughing, sputum is yellow and sticky
  • tachypnea, prolonged expiration
  • tachycardia
  • chest tightness
  • suprasternal retraction
  • restlessness
  • anxiety
  • cyanosis
  • Altered loc
  • Changes in ABGs
Nursing Diagnosis
  • Impaired gas exchange RT ventilation perfusion imbalance AEB dyspnea, tachypnea, and tachycardia

May be related to

  • altered delivery of inspired O2 or air trapping
Planning
  • Patient will improve gas exchange AEB absence of respiratory distress
  • Patient will demonstrate improved ventilation and adequate oxygenation of tissues by ABG’s within client’s normal limits and absence of symptoms of respiratory distress.
  • Patient will verbalize understand of causative factors and appropriate interventions (deep breathing, cough exercises, etc)
Nursing Interventions
  • Assess vital signs, noting respiratory rate, depth, and rhythm.
    • Rationale: To obtain baseline data
  • VS monitor and record
    • Rationale: Serve to track important changes
  • Auscultate breath sounds and assess airway pattern
    • Rationale: to check for the presence of adventitious breath sounds
  • Elevate head of the bed and change position of the pt. every 2 hours.
    • Rationale: To minimize difficulty in breathing and promote maximum lung expansion.
  • Encourage deep breathing and coughing exercises.
    • Rationale: To maximize effort for expectoration.
  • Demonstrate diaphragmatic and pursed-lip breathing.
    • Rationale: To decrease air trapping and for efficient breathing.
  • Encourage increase in fluid intake
    • Rationale: To prevent fatigue.
  • Encourage opportunities for rest and limit physical activities.
    • Rationale: To prevent situations that will aggravate the condition
  • Reinforce low salt, low fat diet as ordered.
    • Rationale: To mobilize secretions.

Fatigue
Assessment

Patient may manifest: 

  • Generalized weakness
  • Verbalization of overwhelming lack of energy
  • Inability to maintain usual routines
  • Tired
  • Lethargic
  • Compromised concentration
  • Decreased performance
Nursing Diagnosis
  • Fatigue r/t physical exertion to maintain adequate ventilation AEB use of accessory muscles to breathe
Planning
  • Patient will verbalize understand on health teachings given and report improved sense of energy.
  • Patient will perform ADL’s within client’s ability and participates in desired activities.
  • Patient will be able to identify basis of fatigue and be able to cope up with the problem.
Nursing Interventions
  • Establish rapport
    • Rationale: To gain patient’s trust
  • Monitor and record vital signs.
    • Rationale: For baseline data.
  • Provide environment conducive to relief of fatigue.
    • Rationale: Temperature and level of humidity are known to affect exhaustion.
  • Assist client to identify appropriate coping behaviors.
    • Rationale: Promotes sense of control and improves self-esteem.
  • Encourage patient to restrict activity and rest in bed as much as possible.
    • Rationale: Helps counteract effects of increased metabolism.
  • Avoid topics that irritate or upset patient. Discuss ways to respond to these feelings.
    • Rationale: Increased irritability of the CNS may cause patient to be easily excited, agitated and prone to emotional outbursts.
  • Discuss with the patient the need for activity. Plan schedule with patient and identify activities that lead to fatigue.
    • Rationale: Education may provide motivation to increase activity level even though patient may feel too weak initially.
  • Alternate activity with rest periods.
    • Rationale: Prevents excessive fatigue.
  • Monitor VS before and after activity.
    • Rationale: Indicates physiological levels of tolerance.
  • Increase patient participation in ADL’s as tolerated.
    • Rationale: Increases confidence level and/or self-esteem and tolerance level

Risk for Activity Intolerance
Assessment
  • Not applicable. Presence of signs and symptoms will establish an actual nursing diagnosis. 
Nursing Diagnosis
  • Risk for Activity Intolerance r/t decrease oxygenation
Planning
  • Patient will participate willingly in necessary/ desired activities such as deep breathing exercises.
  • Patient will perform ADL’s within client’s ability and participates in desired activities.
  • Patient will be able to increase activity tolerance AEB attendance of self-care needs.
  • Patient will be able to gradually increase activity within level of ability
Nursing Interventions
  • Monitor VS.
    • Rationale: For baseline data.
  • Assess motor function.
    • Rationale: To identify causative factors.
  • Note contributing factors to fatigue.
    • Rationale: To identify precipitating factors.
  • Evaluate degree of deficit.
    • Rationale: To identify severity.
  • Ascertain ability to stand and move about.
    • Rationale: To identify necessity of assistive devices.
  • Assess emotional or psychological factors
    • Rationale: Stress and/or depression may increase the effects of illness.
  • Plan care with rest periods between activities
    • Rationale: To reduce fatigue
  • Increase activity/exercise gradually such as assisting the patient in doing PROM to active or full range of motions.
    • Rationale: Minimizes muscle atrophy, promotes circulation, helps to prevent contractures
  • Provide adequate rest periods.
    • Rationale: To replenish energy.
  • Assist client in doing self care needs
    • Rationale: To promote independence and increase activity tolerance
  • Elevate arm and hand
    • Rationale: Promotes venous
  • Place knees and hips in extended position
    • Rationale: Maintains functional

Other Possible Nursing Care Plans
  • Anxiety—may be related to perceived threat of death, possibly evidenced by apprehension, fearful expression, and extraneous movements.
  • Risk for contamination—risk factors may include presence of atmospheric pollutants, environmental contaminants in the home.
Sample NCP