ASSESSMENT
Relevant Data
Age 7
Male
Weight 26.8 kg
PMHX- asthma
Allergies – eggs, milk, dairy
and nuts
Presented in ED with SOB,
cough, fever, wheezing. X3
days.
Assessment on Day 1
Vitals – 0800h
T 36.5 AX
HR 154
Resps 23
BP 95/58
SpO2 96%
2L Oxygen NP
Pain – 0/10
Alert and oriented X 3
Cap refill less than 2 seconds.
Patient using abdominal
muscles to assist with
respirations, intercostal
indrawing. No nasal flaring or
tracheal tug noted. Pt. able to
speak full sentences between
breaths.
Occasional dry, nonproductive cough
Air entry very diminished
ANALYSIS
Nursing
Diagnosis
Ineffective
breathing
pattern r/t
inflamed
bronchial
passages,
and
respiratory
muscle
fatigue AEB
shortness
of breath,
coughing
and
accessory
muscle
use.
PLAN
Expected
Outcomes
Goal:
The patient will
demonstrate
breathing
pattern within
normal limits
and no longer
require
supplemental
oxygen.
Expected
Outcomes:
The patient will:
1. Report ability
to breathe
comfortably
by end of
shift
2. Patient will
require less
frequent
ventolin
treatments
by 24 hours
postadmission
PLAN
IMPLEMENTATION
EVALUATION
Of Expected
Outcomes
Interventions
Rationale
Effectiveness of
Interventions
1. Monitor respiratory
rate, depth, and
ease of respirations
q4h and prn
Monitoring trends in
respiratory status will
demonstrate
improvements or
worsening respiratory
status. (Wilson &
Smith, 2004 as cited in
Ackley & Ladwig,
2010)
Respiratory rate went
from mildly tachypneic at
23 breaths per minute to
18 breaths per minute
which is in the normal
range for this client’s
age
Goal partially
met.
2. Note abdominal
breathing, use of
accessory muscles,
nasal flaring,
retractions,
irritability,
confusion or
lethargy q4h
These symptoms
signal increasing
respiratory difficulty
and increasing hypoxia
(Jones & Smith, 2008
as cited in Ackley &
Ladwig, 2010)
At the beginning of the
shift, the client was using
abdominal muscles to
breathe and had
intercostal indrawing.
This subsided over the
course of the shift.
2. Air entry
improved
(less tight,
less
wheezy)
during shift
therefore
less
ventolin
needed
3. Monitor Sp02
continuously and
blood gases as
ordered.
Oxygen saturation less
than 90% (normal 95100 %) or a partial
pressure of oxygen of
less than 80% (normal
80-100%) indicates
significant
oxygenation problems
(Berry and Penard,
2002; Grape, 2002).
Over the course of the
shift, the client was able
to be weaned from
2L/min of oxygen via
nasal prongs to 1L/min
and maintain his
saturations greater than
94%
Wheezing had decreased
during the shift,
1. Patient did
report
feeling
“better” by
end of shift
3. accessory
and
abdominal
muscle use
not evident
by end of
shift
4. respiratory
rate
normalized
(“tight”) throughout all lung
fields with inspiratory and
expiratory wheezing
bilaterally to bases. Wheezing
coarser to right lower lobe.
Abdomen soft, nondistended, bowel sounds
present x 4 quadrants.
Vitals – 1200h
T 36.6
HR 137
Resps 18
BP 105/57
Sp02 97%
1L Oxygen NP
Pain 0/10
Pt. no longer using abdominal
muscles to breath. No
intercostal indrawing, no
tracheal tug or nasal flaring. Pt
able to speak in full sentences
between breaths.
Air entry improved (“less
tight”) with mild wheezing on
inspiration and expiration
bilaterally to bases. Wheezing
remains increased to right
side.
Air entry much improved and
less wheezy post-ventolin
treatments
Patient reports feeling better
No other changes from
previous assessment.
3. Respiratory
rate will
return to
normal limits
for age
within 24
hours of
admission
4. Air entry will
be clear and
equal
bilaterally to
all lobes by
day 2 of
admission
5. No nasal
flaring,
tracheal tug,
or accessory
muscle use
noted by day
2 of
admission
6. SpO2 will be
greater than
94% on room
air by day 2
of admission
4. Auscultate breath
sounds every 4
hours and when
required, noting
decreased or
absent sounds,
crackles, or
wheezes.
5. Administer oxygen
as required.
6. Position patient in
an upright or semiFowler’s position
when awake
7. Administer
medications such as
bronchodilators or
inhaled steroids as
ordered
These abnormal lung
sounds can indicate a
respiratory pathology
associated with an
altered breathing
pattern. (Ackley &
Ladwig, 2004)
Oxygen therapy helps
decrease dyspnea
through reduction in
the central drive
mediated via
peripheral chemoreceptors in the
carotid body (Meek,
1999).
An upright position
facilitates lung
expansion. (Ackley &
Ladwig, 2004)
Appropriate and
timely use
medications can
decrease the risk of
exacerbating
ineffective breathing
(Ackley & Ladwig,
2004)
especially after each
ventolin treatment. Air
entry also improved
becoming less tight over
the course of the shift
Able to wean oxygen
from 2L/min to 1L/min
during shift
Head of bed remained
elevated to high-Fowler’s
position during day
Ventolin was ordered
q2h on admission.
During course of shift
went to q4h and then
ordered on a prn basis.
from
23/min to
18/min
5. patient
remained
on oxygen
at end of
shift
6. frequency
of ventolin
treatments
changed
from q2h to
q4h to prn