Escolar Documentos
Profissional Documentos
Cultura Documentos
605
Ineffective airway clearance related to bronchospasm, excessive mucus production, tenacious secretions, and fatigue
as evidenced by ineffective cough, inability to raise secretions, adventitious breath sounds
1. Maintains clear airway with removal of excessive secretions
2. Experiences normal breath sounds and respiratory rate
OUTCOMES (NOC)
Respiratory Status: Airway Patency
Measurement Scale
1 = Severely compromised
2 = Substantially compromised
3 = Moderately compromised
4 = Mildly compromised
5 = Not compromised
NURSING DIAGNOSIS
PATIENT GOALS
Anxiety related to difficulty breathing, perceived or actual loss of control, and fear of suffocation as evidenced by restlessness,
elevated pulse, respiratory rate, and blood pressure
1. Reports decreased anxiety with increased control of respirations
2. Experiences vital signs within normal limits
OUTCOMES (NOC)
Anxiety Level
Restlessness _____
Increased blood pressure _____
Increased pulse rate _____
Increased respiratory rate _____
Verbalized anxiety _____
Facial tension _____
Measurement Scale
1 = Severe
2 = Substantial
3 = Moderate
4 = Mild
5 = None
NURSING DIAGNOSIS
PATIENT GOALS
Deficient knowledge related to lack of information and education about asthma and its treatment as evidenced by frequent
questioning regarding all aspects of long-term management
1. Describes the disease process and treatment regimen
2. Demonstrates correct administration of aerosol medications
3. Expresses confidence in ability for long-term management of asthma
OUTCOMES (NOC)
Asthma Self-Management
Measurement Scale
1 = Never demonstrated
2 = Rarely demonstrated
3 = Sometimes demonstrated
4 = Often demonstrated
5 = Consistently demonstrated
*See Tables 29-7, 29-8, 29-10 and Fig. 29-7.