- Activity Intolerance related to Airway constriction and Imbalance between oxygen supply and demand as evidenced by Dyspnoea on exertion and poor sleep due to dyspnoea or coughing
- Impaired Gas Exchange related to bronchospasm and respiratory fatigue as evidenced by Dyspnoea and Hypoxia, Hypercapnia
- Ineffective Airway Clearance related to mucus secretion and exposure to triggers as evidenced by abnormal breath sounds and Cough
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: -Patient’s report of decreased activity/weakness -Shortness of breath with exertion -Fatigue -Exertional discomfort Objective data: -Abnormal blood pressure and heart rate response to activity -Changes to ECG -Signs of pain with movement/activity -Difficulty engaging in activity -Increased oxygen demands | Activity Intolerance related to Airway constriction and Imbalance between oxygen supply and demand as evidenced by Dyspnoea on exertion and poor sleep due to dyspnoea or coughing | Patient will complete ADLs without dyspnea or wheezing. Child will participate in play without shortness of breath or coughing. | 1. Encourage progressive activity. Exercise is necessary for health. Encourage activities such as walking or yoga which are generally safe for asthmatics. The patient should limit their sedentary time and alternate between rest and activity to improve their tolerance. 2. Educate on triggers. Educate patients to consider the elements before engaging in outdoor activity. Allergens, smoke, humidity, and cold temperatures can trigger asthma attacks. 3. Offer other activities. Children who are not able to participate in high-endurance activities such as soccer or running can instead play games, crafts, or sports such as gymnastics or golf. 4. Plan for exercise. Exercise-induced asthma requires preparation to prevent attacks. Medication should be taken before engaging in exercise, a thorough warm-up prepares the lungs for vigorous exercise, and the patient should monitor their respiratory status closely and know when to stop or reduce their effort. | Patient completed ADLs without dyspnea or wheezing. Child participated in play without shortness of breath or coughing. |
| Subjective data: -Dyspnea -Diaphoresis (excessive sweating) -Visual disturbances -Headaches Objective data: -Altered respiratory patterns -Restlessness -Lethargy -Cyanosis -Confusion -Abnormal arterial blood gas values or blood pH -Increased heart rate -Decreased oxygen saturation | Impaired Gas Exchange related to bronchospasm and respiratory fatigue as evidenced by Dyspnoea and Hypoxia, Hypercapnia | Patient will display an improvement in ventilation and oxygenation as evidenced by ABGs within normal limits. Patient will be free of signs of respiratory distress. Patient will verbalize symptoms requiring provider notification or emergency assistance. | 1. Apply oxygen. Supplemental oxygen is commonly applied during asthma exacerbations for hypoxia. 2. Monitor ABGs. For severe asthma attacks, ABG results reveal hypoxemia, hypercarbia, and respiratory alkalosis or acidosis and guide further treatment. 3. Administer medications as prescribed. Albuterol is a bronchodilator administered for acute asthma symptoms to open the airways. Corticosteroids are commonly administered to reverse inflammation. 4. Prepare for intubation. A small percentage of patients with asthma exacerbations will require ICU admission and intubation. Prepare for intubation if the patient does not respond to initial treatment, demonstrates mental status changes, or if ABG results reveal impending respiratory arrest. | Patient displayed improvement in ventilation and oxygenation as evidenced by ABGs within normal limits. Patient free from signs of respiratory distress. Patient verbalized symptoms requiring provider notification or emergency assistance. |
| Subjective data: Dyspnea Objective data: -Adventitious breath sounds -Abnormal respiratory rate, rhythm, and depth -Declining oxygen saturation -Ineffective or absent cough reflex -Copious mucus production -Orthopnea -Cyanosis | Ineffective Airway Clearance related to Mucus secretion and exposure to triggers as evidenced by abnormal breath sounds and Cough | Patient will maintain a patent airway. Patient will be able to expectorate secretions effectively. Patient will display clear breath sounds | 1. Elevate the head of the bed. Sitting upright often makes breathing easier and encourages drainage of secretions. 2. Administer anticholinergics. Ipratropium bromide is an anticholinergic that can be administered via inhaler or nebulizer that reduces mucus secretion. 3. Reduce exposure to allergens. It is imperative to reduce allergen exposure to triggers such as dust mites, pollen, smoke, mold, or animal dander. 4. Explain and assist in the proper use of a nebulizer or MDI (metered dose inhaler). Educating the patient and their family on the use of MDIs or nebulizers ensures that medication delivery to the airways is appropriately executed. | Patient maintained patent airway. Patient expectorated secretions effectively. Patient displayed clear breath sounds |