UNIVERSITY OF TENNESSEE AT CHATTANOOGA
SCHOOL OF NURSING
CARE PLAN
Assessment
Subjective:
-Pt states “I
cook, clean,
and dance at
home without
getting tired.”
-Pt states “I
walk up my
stairs at home
just fine.”
-Pt reports
regular daily
walks around
neighborhood.
Nursing
Diagnosis
Activity
intolerance
r/t
bronchospasms
secondary to
asthma AEB
exertional
discomfort,
exertional
dyspnea,
exertional chest
pain, fatigue, and
weakness
Rationale:
Dyspnea
secondary to
- Pt reports
asthmatic
fatigue and
bronchitis has
weakness after been shown to
walking short
“lead to fatigue,
distances in
poor exercise
last 3 weeks.
endurance,
limited physical
-Pt reports
activity, and
feeling like
poor quality of
she cannot
life” (Ubolnuar
breathe when
et al., 2022). The
performing her ineffective
normal ADLs airway clearance
in last 3
is causing this
weeks.
patient’s
dyspnea, which
- Pt reports a
in turn is causing
pinching chest the activity
pain located
intolerance. In
under left
order to correct
breast.
the activity
Describes it as intolerance, the
radiating from patient’s airway
breast to back must first be
and said its
stabilized.
onset was
Similarly,
during “one of according to the
Planning: Goals &
Intervention
Goal: Patient will
ambulate for 6 minutes
continuously without
showing signs of
dyspnea by 0800 on
4/13/23
Interventions:
1.1 Beginning on
4/10/23, the nurse
will assess the
patient’s tolerance
to ambulation by
monitoring for
signs of dyspnea at
1000 daily until
4/13/23.
1.2 The nurse will
educate the patient
on the use of
pursed lip
breathing when
ambulating and
verify knowledge
using teach-back
method to control
dyspnea and
increase activity
tolerance at 1100
on 4/10/23.
Implementation/Rationale Evaluation
for interventions
If the patient met
the goal, the nurse
would expect the
patient to
ambulate
continuously for 6
minutes without
having difficulty
breathing.
1.1 Assessment of
dyspnea “can improve
management and relieve
suffering” (Baker et al.,
2017).
It is important to “assess
an individual’s
capabilities and energy
levels in order to prepare
a personalized exercise
routine that is consistent
with each individual’s
abilities and needs”
(Emfietzoglou, 2023).
1.2 “Purse-lip breathing
is a technique that allows
people to control their
oxygenation and
ventilation. The technique
requires a person to
inspire through the nose
and exhale through the
mouth at a slow
controlled flow. Through
purse-lip breathing,
people can have relief of
shortness of breath,
decrease the work of
breathing, and improve
gas exchange. They also
regain a sense of control
over their breathing…”
my normal
daily walks.”
-Pt reports
having a
wheeze prior
to admission
to hospital.
ABCs, the
airway and
breathing must
take priority
before moving
on to other
diagnoses.
(Nguyen & Duong,
2022).
When engaging in
pursed-lip breathing,
“more air is able to flow
in and out of your lungs
so you can be more
physically active”
(American Lung
Association, 2022).
Objective- pt prescribed
“It is crucial to gear oral
instructions to patients… to
ensure that patients
understand health
information and
instructions and perform
self-care… By using the
teach-back method, HCPs
can assess patients’
understanding, and reteach
or modify teaching if
comprehension is not
demonstrated (Yen &
Leasure, 2019).
albuterol
breathing
treatment Q6H
per nurse.
- pt prescribed
steroids per
chart.
- Patient
presented to the
ED with acute
bronchospasms
per chart.
1.3 Beginning at 1200
on 4/10/23, the
nurse will
implement active
LE ROM
exercises, focusing
on each joint in
LE, doing each
exercise 10 times
and holding for 30
seconds, once per
shift when patient
is awake as
tolerated by patient
until 4/13/23 at
0800.
1.3 “The atrophy of leg
muscles… increases
ventilation and
breathlessness…
Breathlessness leads to
inactivity, which leads to
muscle deconditioning,
which itself drives
breathlessness, and
further reductions in
activity” (Moxham &
Jolley, 2009).
Active ROM exercises
are associated with
increases muscle strength
and hypertrophy
(Schoenfeld & Grgic).
When implementing LE
ROM exercises, “do each
exercise 10 times or move
to the point of resistance
and hold for 30
seconds” (ALS
worldwide, 2004)
1.4 Beginning on
4/10/23 at 0800,
the nurse will
encourage the
patient to pace
themself when
ambulating until
0800 on 4/13/23.
1.4 “The aims of activity
pacing include to reduce
overactivity–
underactivity cycling
(fluctuating between high
and low levels of activity)
in order to improve
overall function and
reduce the likelihood of
exacerbating symptoms”
(Res, 2018).
Pacing “can prevent
exhaustion and episodes
of breathlessness if
patient can know their
limits and not push
beyond them” (Booth et
al., 2011).
1.5 The nurse will
educate the patient
on proper upper
body positioning
and posture during
ambulation and
verify knowledge
using teach-back
method to make
efficient use of
accessory muscles
and decrease
dyspnea at 0100 on
4/10/23.
1.5 “Poor posture
significantly reduces lung
capacity [and] expiratory
flow” (Kang et al., 2016).
Positioning shoulder
girdles and upper limbs
in a “forward lean…
[makes] efficient use of
breathing accessory
muscles [and] facilitates
abdominal contents
forward so
diaphragm movement not
hindered” (Booth et al.,
2011).
“It is crucial to gear oral
instructions to patients… to
ensure that patients
understand health
information and
instructions and perform
self-care… By using the
teach-back method, HCPs
can assess patients’
understanding, and reteach
or modify teaching if
comprehension is not
demonstrated (Yen &
Leasure, 2019).
Approved by Faculty Organization, 11/9/2021