Respiratory Group 4 – Y1 – 3
Duran, Frances Sofia A.
Baltazar, Khaila
San Pedro, Nicole
Hobayan, Herlin
Cajanding, Richelle
Tuazon, Angel
Morales, Abbie
Santos, Ma. Judea Perinne
Tibay, Jhon selvon
Tayactac, Raphael
Cruz, Alvin
Peleña
CASE SCENARIO
Patient J.W.D.B an 8-year-old client was brought to the clinic for chief complain of Difficulty of Breathing during the interview the client stated “Nahihirapan
po ako huminga”. According to the guardian, as she was cleaning the house, the child started to show signs and symptoms of an allergic reaction. The
guardian (cousin) further reported that the child started to rub her nose and eyes until it became red and puffy, after an hour she notices that the child is
using her muscles to aid in breathing,. According to the mother of the patient the was child was medically diagnosed with asthma since she was 1 year
old (2015). The child presented with signs and symptoms of asthma ever since she was 6 months old, and her physician advised her parents for closed
monitoring. Six months later, it was confirmed that she has asthma. The child is then prescribed with Combivent (Nebulizer), Ventolin Inhaler (with
spacer), and montelukast as her pharmacological treatment for asthma. In lined with her genetic inheritance, the child has a family medical history of
asthma in the client’s mother side. Her mother reported that patient J.W.D.B. has an asthma attack every time she is exposed with hot or cold weather,
a strong scent of cologne, inhaled dust, or either cigarette or vehicle smokes.
ASSESSMENT NURSING ANALYSIS/ GOALS AND INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS INFERENCE OBJECTIVES
Subjective data: Ineffective Ineffective airway SHORT TERM: INDEPENDENT GOAL WAS MET
• “Nahihirapan po airway clearance refers to the • Assist the client in • This will promote
ako huminga” clearance inability of the client to Within 5-10 minutes of maintaining a maximum lung
stated by the related to effectively clear secretions nursing intervention the comfortable expansion and will
client during the airway or obstructions from the patient will be able to: position to facilitate aid in breathing of
interview. constriction and airway, leading to breathing by the Client.
mucus compromised oxygenation elevating the head
• According to the production as and ventilation. (Wayne, 1. The client will be of the bed, leaning 1. After 5 minutes of
guardian, “as evidenced by G., 2022). able to breathe on or over the bed nursing
she was bilateral without difficulty. table, or sitting at interventions the
cleaning the wheezing and In our case study, the child the edge of the client was able to
house, the child crackles in lung is medically diagnosed bed. breathe without
started to show auscultation. with asthma and wherein the aid of
signs and she has compromised • Exercise lungs and accessory
• Effective breathing
symptoms of an airway due to promote adequate muscles in sitting
techniques (Deep
allergic reaction inflammation and gas exchange, and position.
breathing
and suddenly constriction of the techniques and promote
experiencing bronchioles making the coughing expectoration of
difficulty of airway narrow and techniques) mucus secretions,
2. The client will be
breathing. obstructed by excessive effective breathing 2. After 5 minutes of
able to perform
mucus production. This patterns will reduce health teaching
Deep breathing
Objective data: causes the presenting the use of accessory the client was
technique, able to perform
signs and symptoms such muscle and will
coughing deep breathing
• AuscultationBil as difficulty of breathing, preserve client’s
techniques. techniques,
ateral Wheezing chest tightness, energy.
and crackles decreased oxygen respiratory rate
upon saturation and increased • Reduce anxiety to decreased from
• Relaxation
auscultation. respiratory effort (use of patient and reduce 30 Bpm to 25
techniques (Guided
accessory muscles). risk of Bpm.
imagery)
hyperventilation.
• Inspection: Wayne, G. B. (2022,
March 19). 3. The client will be • Increased fluid • Hydration helps 3. The client was
Using accessory
able to perform intake decrease the able to perform
muscles
Ineffective Breathing relaxation viscosity of guided imagery
(Shoulder
Pattern Nursing Care techniques. secretions, and remained
blades)
Plan. Nurseslabs. facilitating calm and
Retrieved April 23, 2022, expectoration. cooperative with
• Inspection:
from the Nurse.
Nose flaring.
https://nurseslabs.com/ine
ffective- breathing-pattern/
Measurements: DEPENDENT: DEPENDENT: LONG TERM:
• RR: 30 Bpm LONG TERM:
Trigerring factors: • Oxygen • After 1 month of
• O2sat: 94% • Administer 2-3 liters
Exposure to allergens • After 1 month of administration will aid nursing
of oxygen via
such as dusts, vehicle nursing in adequate tissue interventions the
facemask as
smoke, tobacco smoke. management, perfusion during client was able to
prescribe.
teachings the acute asthma maintain a patent
client will be able attacks. Oxygen airway without
to maintain a supplementation wheezing and
patent airway and reverses/prevents crackles through
Asthma: will perform hypoxemia. auscultation
Bronchoconstriction, coping techniques
increased mucus during acute
secretion and excacerbations. • Inhaled ß2-
• Administer
inflammation medication adrenergic agonists
bronchodilators as are first-line
prescribe and as therapies for rapid
needed. symptomatic
(Salbutamol, improvement of
Albuterol) bronchoconstriction.
Presenting signs and These medications
symptoms: relax smooth
Reduced O2 Saturation, muscles and reduce
increased respiratory rate, local congestion,
uses accessory muscles reducing airway
and nasal flaring, cough, spasm, wheezing,
wheezing, crackles during and mucus
auscultation. production.
Medications may be
oral, injected, or
inhaled.
COLLABORATIVE: COLLABORATIVE:
Ineffective airway
clearance related to • Refer to a • Respiratory
bronchoconstriction and respiratory therapists specialize
as evidenced by therapist for in managing patients
Bilateral wheezing ans physiotherapy and requiring ventilatory
crackles lung sounds. nebulizer support. They
treatments as implement strategies
needed. to help the patient
wean successfully
from the mechanical
ventilator and
prevent
complications post-
mechanical
ventilation.
