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8 y/o male diagnosed with status asthmaticus - Coggle Diagram
8 y/o male diagnosed with status asthmaticus
labs
CBC
ABG
tests
pulmonary function test
peak expiratory flow
continuous SPO2 monitoring
meds
epinephrine: 1 mL PRN for poor air intake
nacl 0.8 : 68 mL/hr for hydration
aerosol ventolin: 2 puffs every 4 hours to dilate bronchioles
10 L high flow nasal cannula to improve O2 levels
nursing diagnosis: Ineffective airway clearance R/T bronchospasms and increased pulmonary secretions AEB abnormal breath sounds and inability to remove airway secretions
long term goal: Pt will identify and avoid specific factors that inhibit effective airway clearance
long term evaluation: pt is able to identify irritants that exacerbate asthma
short term evaluation: Pt airway has less secretions and is able to maintain clear, open airways
interventions with rationale
use pulse oximetry to monitor oxygen saturation: oxygen saturation should be maintained at 90% or greater
maintain humidified oxygen as prescribed: increasing humidity of inspired air will reduce thickness of secretions and aid their removal
assess airway for patency: maintaining patent airway is always the first priority
if secretions cannot be cleared, consider the need for an intubation: readiness for an emergency helps prevent further complications
short term goal: pt will demonstrate increased air exchange
nursing diagnosis: Fear R/T breathlessness AEB statements of "I'm going to die"
long term goal: pt will understand that fear is a natural feeling to have during a stressful time.
long term outcome
short term outcome: pt has calmed down and is less fearful
interventions with rationale
open up about your awareness of the patient's fear. This approach validates the feelings the patient is holding and demonstrates recognition of those feelings
use simple language and easy to understand statements regarding diagnostic procedures. simple, clear, and brief instructions are necessary
be with the patient to promote safety especially during frightening procedures or treatment. The physical connection with a trusted person helps the patient feel secure and safe during a period of fear
evaluate the measures the patient practices to cope with that fear. This information helps determine the effectiveness of coping strategies used by the patient
short term goal: patient will demonstrate a reduction in fear
nursing diagnosis: Deficient knowledge R/T chronicity of disease AEB ineffective self-care
long term goal: pt and mother will be able to manage the disease without intervention from the hospital
long term outcome: pt and mother understand how to manage the disease long term and how to prevent and emergency situation by recognizing signs and symptoms early
short term outcome: pt and mother verbalize understanding of the disease
interventions with rational
assess past and present therapies, including the client's response to them. Knowledge of what has been effective in the past determines the appropriate intervention needed
instruct the client how to avoid asthma triggers: smoke, exercise, air pollution, allergens. Environmental trigger control ca lessen the frequency of asthma attacks and improve the client's quality of life
assess the client's knowledge of care for status asthmaticus. Knowledge of how to handle care can save time
educate the client about the warning signs and symptoms of an asthma attack and the importance of early treatment of an impending attack. A written treatment plan is needed by the client to reinforce information that was already taught
short term goal: pt and mother will verbalize knowledge of the disease
nursing diagnosis: fatigue R/T increased work of breathing AEB tachypnea
long term goal: pt will be able to preform usual activities
long term outcome: pt will resume usual activities before the event occurred
short term outcome: pt demonstrated decreased fatigue by being able to tolerate more activities
interventions with rational
monitor vital signs every 4 hours. monitor frequency of work of breathing. Identifying and notifying changes allows immediate action that find a solution to the problem and minimize the occurrence of fatigue
encourage simple, quiet, age appropriate play activities as the child condition improves. Physical and emotional comfort has a positive effect on the general well-being, encourages relaxation and decreases oxygen consumption and fatigue
allow the presence of a parent. the presence of others minimizes anxiety and fear hence it can lessen oxygen expenditure and fatigue
assess for signs of hypoxia such as change of level of consciousness, SOB, tachycardia, irritability, fatigue, restlessness. determining these symptoms immediately allows timely management and minimizes fatigue
short term goal: pt will demonstrate decreased fatigue