Asthma Nursing Care Plans - Lippincott

Asthma
Revised: May 6, 2016
Acute Confusion
Related to:
Chronic oxygen deficit
Other:
Evidenced by:
Altered level of consciousness
Behavioral changes (agitation, restlessness)
Changes in cognition
Changes in psychomotor activity
Difficulty initiating and/or following through with goal-directed or purposeful behavior
Hallucinations
Impaired perceptions
Other:
Expected Outcomes
The patient will be free from injury.
The patient will participate in self-care activities.
The patient will be calm.
The patient will demonstrate stable neurologic status.
Other:
Nursing Interventions
Independent
Allow the patient time to perform tasks and provide cues, as necessary.
Assess for fall risk.
Assess the patients neurologic status every:

o
15 minutes
30 minutes
1 hour
2 hours
4 hours
8 hours
other: _________________________________________.
Assess vital signs every:

o
15 minutes
30 minutes
1 hour
2 hours
4 hours
8 hours
other: _________________________________________.
Assist in determining underlying cause of acute confusion, as indicated. Perform a

comprehensive assessment.
Assist the patient with activities of daily living, as needed. Offer toileting or hygiene
activities at scheduled intervals.
Ensure that dentures, glasses, and hearing aids are available.
Explain all tests and procedures to the patient. Keep explanations simple and
concrete.
Explain routines and changes in routines to the patient.
Have lighting follow normal sleep/wake patterns.
Provide a safe environment for the patient. Initiate safety measures as indicated;
include alert devices (personal alarm, bed alarm) especially during the night, as
appropriate.
Provide aids to assist in orientation (clocks, calendar).
Reduce noise and environmental stimulation.
Reorient the patient as needed.
Other:
Collaborative
Administer medications, as prescribed, and assess response.
Ask the family to provide pictures and other familiar objects from home.
Continually monitor the patient as indicated by his condition.
Encourage family to visit the patient as appropriate.
Provide for consistency of staff in caring for the patient.
Treat the underlying condition as prescribed, and monitor for response.
Other:
Evaluation
The patient is free from injury.
The patient participates in his self-care activities.
The patient is calm and nonviolent.
The patient demonstrates stable neurologic status.
Other:
Anxiety
Related to:
Acute or chronic illness
Environmental factors
Respiratory distress
Situational crisis
Other:
Evidenced by:
Altered attention span and concentration
Altered sleep habits
Altered vital signs
Behavioral changes
Crying
Diaphoresis
Dyspnea
Verbalization of anxiety
Other:
Expected Outcomes
The patient will display decreased signs and symptoms of anxiety.
The patient will identify factors that promote anxiety and work to modify his response
to them.
The patient will learn and demonstrate effective coping behaviors.
The patient will verbalize decreased anxiety.
The patients vital signs will be within the normal range.
Other:
Independent
Assess for signs and symptoms of anxiety.
Encourage the patient to verbalize his anxieties, concerns, and fears.
Explain all tests and procedures to the patient, using clear, simple explanations.
Help the patient identify coping strategies that have worked in the past and
support the use of these strategies.
Help the patient identify factors that increase anxiety.
Provide care in a calm and reassuring manner.
Provide quiet time, and decrease environmental stimulation.
Teach stress reduction and relaxation techniques.
Use therapeutic communication skills to develop a trusting relationship with the

patient.
Other:
Collaborative
Administer medications, as prescribed, and monitor for effect.
Obtain referrals for counseling and therapy, as needed.
Provide therapies to reduce anxiety, such as music therapy.
Refer the patient to pastoral care, as appropriate.
Other:
Evaluation
The patient displays decreased signs and symptoms of anxiety.
The patient identifies factors that promote anxiety and how to change his response to
them.
The patient demonstrates effective coping behaviors.
The patient verbalizes decreased anxiety.
The patients vital signs are within the normal range.
Other:
Deficient Knowledge: Diagnostic Test

Related to:
Cognitive impairment
Difficulty remembering information
Disinterest in learning
Lack of knowledge of resources
Lack of information
Misinformation by others
Other:
Evidenced by:
Inability to accurately follow instructions
Inability to recall information or demonstrate comprehension
Inappropriate behavior
Poor performance on a test of knowledge or return demonstration
Verbalization of insufficient knowledge
Other:
Expected Outcomes
The patient will be able to state the purpose of the test or procedure.
The patient will be able to verbalize follow-up procedures.
The patient will be able to verbalize what to expect before, during, and after the test
or procedure.
Other:
Independent
Assess for and reduce barriers to learning.
Assess the patients readiness to learn.
Assess what patient the already knows and needs to know about the test or
procedure.
Describe equipment that will be used during the test or procedure.
Determine the need for interpretive services, as indicated.
Determine the patients learning style, and develop appropriate teaching

strategies.
Discuss complications that require immediate medical attention.
Encourage the patient and family to ask questions.
Give the patient the date and time of any follow-up appointments.
Reinforce teaching with written materials.
Teach about the test: explain what to expect before, during, and after the test or
procedure.
Other:
Collaborative
Have the patient meet with the staff member performing the test, as appropriate.
Modify teaching style to accommodate the patients age and/or deficits.
Other:
Evaluation
The patient explains the purpose of the test or procedure.
The patient explains what to expect before, during, and after the test or procedure.
The patient verbalizes the procedures to follow after the test as well as the date and
time of any follow-up appointment.
Other:
Deficient Knowledge: Disease Process

Related to:
Anxiety
Communication barrier or impairment
Cultural or religious beliefs
Disinterest, depression or psychological distress
Lack of knowledge
Lack of resources
Misinterpretation of information
Other:
Evidenced by:
Impaired ability to communicate
Request for information regarding disease process
Verbalized lack of exposure, knowledge, or resources
Verbalized misinterpretation of information
Verbalized or observed anxiety
Verbalized or observed disinterest
Other:
Expected Outcomes
The patient will seek information about the disease process.
The patient will verbalize increased knowledge and comprehension of the disease
process.
The patient will express having a comfortable level of knowledge regarding the
disease process.
The patient will verbalize the ability to make informed decisions about the disease
process.
Other:
Independent
Assess the patients knowledge of the disease process.
Assess cultural and religious beliefs that influence knowledge of the disease
process.
Assess the patients physical and emotional readiness to learn.
Establish realistic goals for learning.
Evaluate the patients comprehension and comfort level with the information
provided.
Provide emotional support as needed.
Provide information regarding the disease process; answer all questions.
Tailor teaching to the patients age, educational level, and preferred method of
learning.
Other:
Collaborative
Enlist the assistance of an interpreter, as needed.
Involve the patients family or caregivers in teaching, as appropriate.
Refer the patient to support groups for the specific disease process, as appropriate.
Other:
Evaluation
The patient seeks information about the disease process.
The patient verbalizes increased knowledge and comprehension of the disease

process.
The patient expresses having a comfortable level of knowledge regarding the disease
process.
The patient verbalizes the ability to make informed decisions about the disease
process.
Other:
Deficient Knowledge: Medications

Related to:
Difficulty remembering information
Disinterest in learning
Lack of knowledge of resources
Lack of information
Misinformation by others
Other:
Evidenced by:
Inability to accurately follow instructions
Inappropriate behavior
Poor performance on a test of knowledge or return demonstration
Verbalization of insufficient knowledge
Other:
Expected Outcomes
The patient will demonstrate increased knowledge and comprehension of medications

and medication instructions.
The patient will demonstrate the ability to comply with the prescribed medication
regimen.
The patient will verbalize an understanding of the daily medication regimen.
The patient will express an understanding of the community resources available to

assist in meeting needs regarding medications.
Other:
Independent
Advise the patient to bring all prescribed and over-the-counter medications to

follow-up practitioner appointments.
Assess the patients knowledge of prescribed medications.
Evaluate the patient and/or caregivers comprehension and comfort level with the
information provided.
Evaluate the patients ability to comprehend written and verbal information.
Instruct the patient to consult the practitioner before taking any over-the-counter
medications, dietary supplements, or herbal drugs.
Provide all information, along with a medication schedule, in writing at a level the
patient can understand; answer all questions.
Review the name, dosage, action, and potential side effects of all prescribed
medications with the patient (and caregiver, if appropriate).
learning.
Other:
Collaborative
Enlist the assistance of an interpreter, as needed.
Obtain a consult with social services, as indicated.
Refer the patient to medication assistance programs, as needed.
Other:
Evaluation
The patient demonstrates increased knowledge and comprehension of medications

and medication instructions.
The patient demonstrates the ability to comply with the prescribed medication
regimen.
The patient verbalizes the daily medication regimen before dismissal.
The patient expresses an understanding of community resources available to assist in

meeting needs regarding medications.
Other:
Deficient Knowledge: Treatment

Related to:
Anxiety or fear
Communication barrier or impairment
Cultural or religious beliefs
Disinterest
Lack of knowledge
Lack of resources
Misinterpretation of information
Other:
Evidenced by:
Inability or impaired ability to communicate
Inability to participate in treatment
Request for information about treatment
Verbalized disinterest
Verbalized lack of exposure, knowledge, or resources
Verbalized misinterpretation of information
Other:
Expected Outcomes
The patient will demonstrate increased knowledge and comprehension of treatment.
The patient will express having a comfortable level of knowledge regarding

treatment.
The patient will verbalize the ability to make informed decisions about treatment.
The patient will verbalize understanding the treatment regimen.
Other:
Independent
Assess cultural or religious beliefs that may impact treatment.
Assess the patients knowledge of treatment.
Evaluate the patients comprehension and comfort level with the information
provided.
Limit the length of teaching sessions to prevent information overload.
Provide emotional support, as needed.
Provide information about treatment; answer all questions.
learning.
Other:
Collaborative
Enlist assistance of an interpreter, as needed.
Involve patients family or caregivers in teaching, as appropriate.
Refer patient to support groups or community resources, as appropriate.
Other:
Evaluation
The patient demonstrates increased knowledge and comprehension of treatment.
The patient expresses having a comfortable level of knowledge regarding treatment.
The patient verbalizes the ability to make informed decisions about treatment.
The patient verbalizes understanding the treatment regimen.
Other:
Fear
Related to:
Diagnostic tests or procedures
Illness or injury
Knowledge deficit
Other:
Evidenced by:
Aggressive behavior
Altered vital signs
Frequent urination
Gastrointestinal disturbance
Labile behavior
Palpitations
Tense muscles
Verbalization of fear
Withdrawal
Other:
Expected Outcomes
The patient will display coping mechanisms that help control fear.
The patient will have normal vital signs.
The patient will identify causes of fear.
The patient will use available support systems.
The patient will verbalize a cessation or a decrease of fear.
The patient will verbalize feelings of fear and anxiety.
Other:
Independent
Assist the patient in identifying causes of fear.
Encourage verbalization of fear and its cause.
Initiate safety measures for the patient, family, and staff.
Provide information that addresses the cause of fear.
Provide active listening.
Provide support to the patient and family.
Reorient the patient, as needed.
Teach relaxation techniques, such as deep breathing and muscle relaxation.
Other:
Collaborative
Contact appropriate clergy, if indicated.
Contact appropriate support groups for assistance.
Consult mental health specialists, as appropriate.
Obtain a case management consult.
Other:
Evaluation
The patient displays coping mechanisms that help control fear.
The patient has normal vital signs.
The patient identifies causes of fear.
The patient uses available support systems.
The patient verbalizes cessation or a decrease of fear.
The patient verbalizes feelings of fear and anxiety.
Other:
Impaired Comfort
Related to:
Situational crisis
Treatment
Other:
Evidenced by:
Anxiety or fear
Change in sleep habits
Crying or moaning
Facial mask of pain
Guarded position
Psychological changes, social withdrawal
Report of discomfort
Other:
Expected Outcomes
The patient will identify discomfort.
The patient will identify factors that increase the discomfort.
The patient will state and carry out ways to decrease discomfort.
The patient will notify the health care practitioner of discomfort before it becomes
unmanageable or unbearable.
The patient will verbalize feelings of comfort.
Other:
Independent
Assess the patients discomfort (characteristics, onset, type, precipitation factors,

and duration).
Assist the patient into a comfortable position.
Educate the patient on ways to decrease factors that precipitate the discomfort.
Educate the patient on what causes the discomfort.
Instruct the patient to notify the practitioner if control measures are inadequate.
Encourage the patient to participate in distraction activities.
Explore factors that relieve or worsen discomfort.
Instruct the patient to notify the caregiver of feelings of discomfort.
Modify measures based on the patients response.
Observe for nonverbal cues of discomfort, such as restlessness, muscle tension, or

altered vital signs.
Schedule care activities to provide the patient with uninterrupted periods of rest.
Other:
Collaborative
Explore complementary therapies with the patient, such as massage therapy,

relaxation therapy, and guided imagery.
Treat the underlying disorder as prescribed, and monitor response.
Other:
Evaluation
The patient identifies discomfort.
The patient identifies factors that increase the discomfort.
The patient states and carries out ways to decrease discomfort.
The patient notifies the health care practitioner of discomfort before it becomes
unmanageable or unbearable.
The patient verbalizes feelings of comfort.
Other:
Impaired Gas Exchange

Related to:
Carbon dioxide retention
Respiratory dysfunction
Ventilation-perfusion imbalance
Other:
Evidenced by:
Abnormal arterial blood gas levels
Change in mental status
Cyanosis, confusion, and lethargy
Decreased oxygen saturation on pulse oximetry
Diminished breath sounds
Dyspnea
Inspiratory and expiratory wheezes
Tachycardia
Use of accessory respiratory muscles
Wheezing and cough, which may be exercise-induced
Other:
Expected Outcomes
The patient will maintain adequate ventilation.
The patient will state an understanding of the causes for impaired gas exchange.
The patient will state or demonstrate behaviors to prevent impaired gas exchange.
The patient will exhibit improved arterial blood gas results from baseline.
Other:
Independent
Assist the patient with activities of daily living.
Auscultate breath sounds every:

o
1 hour
2 hours
4 hours
8 hours
other: _________________________________________.
Group care activities to allow the patient uninterrupted periods of rest.
Monitor heart rate and rhythm every:
15 minutes
30 minutes
1 hour
2 hours
4 hours
8 hours
other: _________________________________________.
Monitor respiratory rate, depth, and effort every:

o
15 minutes
30 minutes
1 hour
2 hours
4 hours
8 hours
other: _________________________________________.
Perform chest physiotherapy every:

o
1 hour
2 hours
4 hours
8 hours
other: _________________________________________.
Perform nasotracheal or endotracheal suctioning every:

o
1 hour
2 hours
4 hours
8 hours
other: _________________________________________.
Place the patient in a position that best facilitates chest expansion.
Teach the patient to cough and deep breathe, and encourage him to do so:
every 1 hour while awake
every 2 hours while awake.
Other:
Collaborative
Administer oxygen as ordered.
Administer medications, as ordered, and monitor for effect.
Assist with incentive spirometry hourly while awake.
Administer nebulizer treatments, as ordered, and monitor for effect.
Monitor arterial blood gas levels.
Monitor pulse oximetry:

o
every 1 hour
every 2 hours
every 4 hours
continuously
other: _________________________________________.
Provide mechanical ventilation, as ordered, and monitor response.
Other:
Evaluation
The patient maintains adequate ventilation.
The patient states an understanding of causes for impaired gas exchange.
The patient states or demonstrates behaviors to prevent impaired gas exchange.
The patients arterial blood gas results are improved from baseline measurements.
Other:
Ineffective Airway Clearance

Related to:
Excessive secretions
Fatigue
Inflammation of airway
Other:
Evidenced by:
Abnormal arterial blood gas values
Altered vital signs and pulse oximetry
Cyanosis
Decreased level of consciousness
Diminished breath sounds
Excessive mucus production
Impaired breathing
Ineffective coughing
Other:
Expected Outcomes
The patient will demonstrate adequate oxygenation and ventilation.
The patient will have decreased mucus production.
The patient will have stable vital signs.
The patient will maintain a patent airway.
The patient will have a productive cough.
Other:
Independent
Assess neurologic status every:

o
1 hour
2 hours
4 hours
8 hours
other: _________________________________________.
Encourage coughing and deep breathing.
Initiate cardiopulmonary resuscitation, as indicated.
Monitor the amount and characteristics of sputum.
Monitor respiratory status every:
1 hour
2 hours
4 hours
8 hours
other: _________________________________________.
Monitor vital signs every:

o
1 hour
2 hours
4 hours
8 hours
other: _________________________________________.
Perform chest physiotherapy every 2 hours.
Reposition the immobilized patient every 2 hours.
Teach the patient and family actions to help maintain a patent airway.
Other:
Collaborative
Administer nebulizer treatments, as ordered.
Administer oxygen therapy, as prescribed.
Instruct the patient on incentive spirometry use and assist hourly.
Monitor arterial blood gases.
every 1 hour
every 2 hours
every 4 hours
continuously
other: _________________________________________.
Obtain a consult with respiratory therapy.
Other:
Evaluation
The patient demonstrates adequate oxygenation and ventilation.
The patient has decreased mucus production.
The patient has stable vital signs.
The patient maintains a patent airway.
The patient has a productive cough.
Other:
Ineffective Breathing Pattern

Related to:
Acute or chronic respiratory disease
Anxiety
Fatigue
Impaired airway
Other:
Evidenced by:
Abnormal breath sounds
Abnormal pulse oximetry reading
Abnormal respiratory rate
Accessory muscle use
Altered arterial blood gas levels
Cyanosis
Dyspnea
Pursed-lip breathing
Other:
Expected Outcomes
The patient will achieve values within the normal range for all laboratory and
diagnostic tests.
The patient will achieve and maintain a regular respiratory rate within _______ breaths
of baseline.
The patient will maintain a patent airway.
The patient will maintain adequate ventilation and oxygenation.
The patient will verbalize increased ease of respirations.
Other:
Independent
Assess for and maintain a patent airway.
Auscultate the lungs every:
1 hour
2 hours
4 hours
8 hours
other: _________________________________________.
Encourage pursed-lip and diaphragmatic breathing.
Group activities to allow the patient uninterrupted periods of rest.
Keep the room temperature comfortable.
Monitor respiratory rate, depth, and effort every:
1 hour
2 hours
4 hours
8 hours
other: _________________________________________.

o
1 hour
2 hours
4 hours
8 hours
other: _________________________________________.
Perform chest physiotherapy, including postural drainage and chest percussion to

all lobes, every:
o
1 hour
2 hours
4 hours
8 hours
other: _________________________________________.
Place the patient in a high Fowler position, unless contraindicated.
Provide emotional support.
Teach and encourage the patient to practice relaxation techniques.
Other:
Collaborative
Administer oxygen as prescribed.
Administer prescribed medications and monitor for effect.
Assist with intubation and mechanical ventilation, as ordered, and monitor

response.
Encourage fluid intake as permitted, or administer prescribed I.V. fluids.
Monitor arterial blood gas levels and pulmonary function test results.

o
every 1 hour
every 2 hours
every 4 hours
every 8 hours
continuously
other: _________________________________________.
Evaluation
The patient achieves values within the normal range for all laboratory and diagnostic
tests.
The patient maintains a regular respiratory rate within _______ breaths of baseline.
The patient maintains a patent airway.
The patient maintains adequate ventilation and oxygenation.
The patient verbalizes increased ease of respirations.
Other:
Risk for Activity Intolerance

Related to:
Imbalance between oxygen supply and demand
Respiratory dysfunction
Trauma
Other:
Evidenced by:
Abnormal vital signs in response to activity
Change in mobility
Exertional dyspnea
History of physical impairment
History of surgery
Injury
Poor nutritional state
Reports of fatigue
Reports of weakness
Other:
Expected Outcomes
The patient will exhibit increased mobility.
The patient will attain and maintain an optimal nutritional status.
The patient will maintain the ability to perform daily activities at the highest level
without abnormal changes in vital signs.
The patient will verbalize feelings of an improved activity status.
Other:
Independent
Assess the patients history for factors that may impair activity tolerance.
Assess the patients response to activities.
Encourage progressive self-care or participation in activities, when tolerated;

identify and acknowledge the patients progress.
Encourage the use of stress management and diversional activities.
Instruct the patient in energy conservation techniques; discuss alternatives with

him, as appropriate.
Limit activities, as indicated, and report changes in abilities.
Monitor vital signs for activity intolerance.
Promote rest periods, as needed.
Provide assistance, as needed.
Review the medication history.
Treat the illness or disease, as appropriate.
Other:
Collaborative
Implement a cardiac rehabilitation or activity program, as ordered, and monitor

response.
Obtain a nutritional consult.
Obtain a physical therapy consult.
Obtain a social services consult.
Provide supplemental oxygen, as ordered.
Other:
Evaluation
The patient exhibits increased mobility.
The patient has attained and maintains an optimal nutritional status.
The patient maintains the ability to perform daily activities at the highest level
without abnormal changes in vital signs.
The patient verbalizes feelings of an improved activity status.
Other:
Risk for Acute Confusion

Related to:
Cardiopulmonary impairment
Other:
Evidenced by:
Abnormal laboratory values
Change in mentation
Change in sleep patterns
Change in vital signs
Other:
Expected Outcomes
The patient will be free from injury.
The patient will be hemodynamically stable.
The patient will be oriented to time, place, and person.
The patient will have normal laboratory values.
Other:
Independent
Assess the patients neurologic status every:

o
15 minutes
30 minutes
1 hour
2 hours
4 hours
8 hours
other: _________________________________________.
Allow the patient time to perform tasks and provide cues, as necessary.
Ask the family to provide pictures and other familiar objects from home.
Assist the patient with activities of daily living, as needed.
Encourage the family to visit the patient.
Explain all tests and procedures to the patient; keep explanations simple and
concrete.
Explain routines and changes in routines to the patient.
Have lighting follow normal sleep/wake patterns.
Initiate safety measures, such as alert devices (personal alarm, bed alarm),
especially during the night.
Offer toileting or hygiene activities at scheduled intervals.
Provide a safe environment for the patient such as by moving him to a room closest
to the nurses station and assessing the need for protective equipment (e.g.,
padded floor, low bed, protective helmet).
Provide for consistency of caregivers.
Reduce noise and environmental stimulation.
Reorient the patient, as appropriate.
Other:
Collaborative
Administer medications, as prescribed, and assess the patients response to them.
Treat the underlying disorder, as ordered, and monitor response.
Other:
Evaluation
The patient is free from injury.
The patient demonstrates hemodynamic stability.
The patient is oriented to time, place, and person.
The patient has normal laboratory values.
Other:
Risk for Decreased Cardiac Tissue Perfusion

Related to:
Arrhythmias
Pulmonary dysfunction
Reduced myocardial perfusion
Substance abuse
Other:
Evidenced by:
Abnormal hemodynamic monitoring values
Abnormal laboratory tests
Abnormal vital signs
Cardiac arrhythmia
Fatigue
Other:
Expected Outcomes
The patient will have adequate urine output.
The patient will maintain adequate cardiac output and hemodynamic stability.
The patient will express an understanding of the prescribed therapeutic regimen.
The patient will identify and reduce risk factors of decreased cardiac tissue perfusion,
as appropriate.
The patient will not develop complications of decreased cardiac tissue perfusion.
Other:
Independent
Assess cardiovascular and respiratory status.
Assess pulmonary status every:

o
1 hour
2 hours
4 hours
8 hours
other: _________________________________________.
Evaluate mental status.
Evaluate the patients response to any arrhythmia.
Group any care activities to provide the patient with uninterrupted periods of rest.
Help the patient identify risk factors and ways to reduce them.
Instruct the patient to report immediately any chest discomfort or pain.
Monitor for cardiac arrhythmias.
Monitor hemodynamic parameters every:
1 hour
2 hours
4 hours
8 hours
other: _________________________________________.
Monitor intake and output every:

o
1 hour
2 hours
4 hours
8 hours
other: _________________________________________.

o
15 minutes
1 hour
2 hours
8 hours
other: _________________________________________.
Monitor weight daily.
Observe for signs of heart failure.
Observe for signs of significant bleeding.
Other:
Collaborative
Administer fluids, as prescribed.
Administer oxygen, as prescribed.
Monitor pulse oximetry every:
1 hour
2 hours
4 hours
8 hours
other: _________________________________________.
Obtain and monitor appropriate laboratory values.
Prepare for diagnostic studies and surgery, as appropriate.
Refer to appropriate support groups and for counseling, as indicated.
Other:
Evaluation
The patient has adequate urine output.
The patient maintains adequate cardiac output and hemodynamic stability.
The patient expresses an understanding of the prescribed therapeutic regimen.
The patient identifies and reduces risk factors of decreased cardiac tissue perfusion,
as appropriate.
The patient does not develop complications of decreased cardiac tissue perfusion.
Other:
Risk for Impaired Cardiovascular Function

Related to:
Family history of heart disease
Knowledge deficit
Medications
Chronic oxygen deficit
Smoking
Other:
Evidenced by:
Abnormal hemodynamic monitoring values
Abnormal laboratory tests (elevated C-reactive protein level,hyperlipidemia)
Abnormal stress-testing results
Abnormal vital signs
Cardiac arrhythmia
Fatigue
Presence of risk factors for heart disease (smoking, sedentary lifestyle,overweight)
Other:
Expected Outcomes
The patient will maintain stable vital signs.
The patient will express an understanding of the prescribed therapeutic regimen.
The patient will identify and reduce risk factors of decreased cardiac tissue perfusion,
as appropriate.
The patient will not develop complications of impaired cardiovascular function.
Other:
Independent
Assess cardiovascular status every:

o
1 hour
2 hours
4 hours
8 hours
other: _________________________________________.
Evaluate the patients response to any arrhythmia.
Group any care activities to provide the patient with uninterrupted periods of rest.
Help the patient identify risk factors and ways to reduce them.
Instruct the patient to immediately report any chest discomfort or pain.
Monitor for cardiac arrhythmias.
Monitor hemodynamic parameters every:

o
1 hour
2 hours
4 hours
8 hours
other: _________________________________________.
Monitor intake and output every:

o
1 hour
2 hours
4 hours
8 hours
other: _________________________________________.

o
15 minutes
1 hour
2 hours
8 hours
other: _________________________________________.
Monitor weight daily.
Observe for signs of heart failure.
Other:
Collaborative
Administer I.V. fluids, as prescribed.
Administer oxygen, as prescribed.
Monitor laboratory studies as ordered.
Monitor pulse oximetry every:
1 hour
2 hours
4 hours
8 hours
other: _________________________________________.
Obtain a consult with the dietitian.
Obtain a physical therapy consult as indicated.
Obtain and monitor appropriate laboratory values.
Refer the patient to appropriate support groups and for counseling, as indicated.
Other:
Evaluation
The patient has stable vital signs.
The patient expresses an understanding of the prescribed therapeutic regimen.
The patient identifies and reduces risk factors of decreased cardiac tissue perfusion,
as appropriate.
The patient does not develop complications of impaired cardiovascular function.
Other:
Risk for Infection

Related to:
Chronic illness
Compromised immune system
Invasive procedure
Other:
Evidenced by:
Abnormal laboratory values
Abnormal sputum production
Abnormal wound drainage
Change in mental status
Change in vital signs
Recent invasive procedure
Other:
Expected Outcomes
The patient will have stable vital signs.
The patient will have normal laboratory values.
The patient or family will state actions that decrease the risk for infection.
The patient or family will verbalize signs and symptoms of infection.
The patient will have normal respiratory secretions.
The patient will not show evidence of infection.
Other:
Independent
Assess the amount and characteristics of sputum.
Assess the amount and characteristics of wound drainage.
Assess the characteristics of urine.
Assess the amount and characteristics of stool.
Assess the wound site every:

o
2 hours
4 hours
8 hours
12 hours
other: _________________________________________.
Auscultate breath sounds every:

o
2 hours
4 hours
8 hours
other: _________________________________________.
Encourage coughing and deep breathing every 4 hours.
Initiate isolation precautions:
airborne
contact
droplet
standard.

o
1 hour
2 hours
4 hours
8 hours
other: _________________________________________.
Provide oral hygiene every 4 hours.
Provide skin care.
Review the signs and symptoms of infection to report to the practitioner.
Suction the patients airway, as needed.
Teach preventive measures of avoiding exposure to infection and methods to

optimize health.
Turn the patient every 2 hours if immobile.
Other:
Collaborative
Administer antibiotics and antipyretics, as prescribed.
Encourage incentive spirometry hourly while the patient is awake.
Monitor I.V. sites; follow facility protocol for changing I.V. tubing and sites.
Monitor laboratory values.
Obtain specimens for culture, as ordered.
Other:
Evaluation
The patients vital signs are within normal limits.
The patients laboratory values are within normal limits.
The patient or family states actions that decrease the risk of infection.
The patient or family verbalizes signs and symptoms of infection.
The patient has normal respiratory secretions.
The patient is free from signs of infection.
Other:
Risk for Injury

Related to:
Altered cognition
Hypoxia
Medication
Other:
Evidenced by:
Abnormal laboratory results
Change in mentation
Change in sensorium
Change in skin appearance or integrity
Impaired mobility
Unsafe behavior
Other:
Expected Outcomes
The patient will remain free from injury.
The patient or family will state environmental or lifestyle changes necessary to

maintain safety.
The patient will demonstrate improved mobility.
The patient will verbalize the medication regimen and demonstrate the correct
method of medication administration.
The patient and family will correctly utilize injury-preventing devices, such as a
pressure-reduction mattress, as appropriate.
Other:
Independent
Assist with feeding as needed.
Assist with mobility (getting out of bed, ambulation), as appropriate.
Institute safety measures; review them with the patient.
Monitor neurologic status every:

o
1 hour
2 hours
4 hours
8 hours
other: _________________________________________.
Turn the patient every 2 hours (if immobile).
Provide surveillance continually as indicated by the patients condition.
Other:
Collaborative
Administer medications as ordered and monitor for effect; review the medication
regimen with the patient.
Monitor laboratory values.
Obtain a physical therapy consult.
Obtain a social services consult.
Utilize a pressure-reduction mattress or overlay, as ordered; monitor response.

Review the use and care of all equipment to be continued in the home
environment.
Other:
Evaluation
The patient remains free from injury.
The patient or family states environmental or lifestyle changes that decrease the risk
for injury.
The patient has improved mobility.
The patient verbalizes the medication regimen and demonstrates the correct method
of medication administration.
The patient and family correctly utilize injury-preventing devices, such as a pressurereduction mattress.
Other:
Selected References
(Rating System for the Hierarchy of Evidence for Intervention/Treatment Questions)
1. Anderson, W. J., et al. (2014). Proof-of-concept evaluation of trough airway hyperresponsiveness following regular racemic or levosalbutamol in genotype-stratified steroid-
treated persistent asthmatic patients. Clinical Science (London, England), 126(1), 7583.
(Level II)
2. Assad, N., et al. (2013). Body mass index is a stronger predictor than the metabolic
syndrome for future asthma in women. The longitudinal CARDIA study. American Journal
of Respiratory and Critical Care Medicine, 188(3), 319326. (Level IV)
Abstract | Complete Reference | Ovid Full Text
3. Chung, K. F., et al. (2014). International ERS/ATS guidelines on definition, evaluation and
treatment of severe asthma. European Respiratory Journal,43(2), 343373. Accessed
December 2015 via the Web athttp://www.guideline.gov/content.aspx?
id=48457&search=asthma (Level I)
Abstract | Complete Reference | Full Text
4. Djukanovi, R., et al. (2014). The effect of inhaled IFN- on worsening of asthma
symptoms caused by viral infections. A randomized trial. American Journal of Respiratory
and Critical Care Medicine, 190(2), 145154. (Level II)
5. Fanta, C. H. Diagnosis of asthma in adolescents and adults. (2014). In:UpToDate, Barnes,
P. J., & Bochner, B. S. (Eds.). Retrieved from:www.uptodate.com
6. Herdman, T. H., & Kamitsuru, S. (Eds.). (2014). NANDA International Nursing Diagnoses:
Definitions & Classification 20152017. Oxford: Wiley Blackwell.
7. Hinkle, J. L., & Cheever, K. H. (2014). Brunner & Suddarths textbook of medical-surgical
nursing (13th ed.). Philadelphia, PA: Wolters Kluwer.
8. Ortega, H. G., et al. (2014). Mepolizumab treatment in patients with severe eosinophilic
asthma. New England Journal of Medicine, 371(13), 11981207. (Level II)
Abstract | Complete Reference | Full Text | Ovid Full Text
9. Sveum, R., et al. (2012). Diagnosis and management of asthma [Online]. Bloomington,
MN: Institute for Clinical Systems Improvement (ICSI). Accessed December 2015 via the
Web at http://www.guideline.gov/content.aspx?id=38255&search=asthma (Level I)
10. Wechsler, M. E., et al. (2015). Anticholinergic vs long-acting -agonist in combination with
inhaled corticosteroids in black adults with asthma: The BELT randomized clinical
trial. JAMA, 314(16), 17201730. (Level II)
Abstract | Complete Reference | Ovid Full Text
11. Wiegand, D. L. (Ed.). (2011). AACN procedure manual for critical care (6th ed.). St. Louis:
MO: Saunders.
Rating System for the Hierarchy of Evidence for Intervention/Treatment

Questions
The following leveling system is from Evidence-Based Practice in Nursing and Healthcare: A
Guide to Best Practice (2nd ed.) by Bernadette Mazurek Melnyk and Ellen Fineout-Overholt.
Level I:
Evidence from a systematic review or meta-analysis of all

relevant randomized controlled trials (RCTs)
Level II:
Evidence obtained from well-designed RCTs
Level III:
Evidence obtained from well-designed controlled trials

without randomization
Level IV:
Evidence from well-designed case-control and cohort

studies
Level V:
Evidence from systematic reviews of descriptive and

qualitative studies
Level VI:
Evidence from single descriptive or qualitative studies
Level VII: Evidence from the opinion of authorities and/or reports of

expert committees
Modified from Guyatt, G. & Rennie, D. (2002). Users' Guides to the Medical Literature. Chicago,
IL: American Medical Association; Harris, R.P., Hefland, M., Woolf, S.H., Lohr, K.N., Mulrow, C.D.,
Teutsch, S.M., et al. (2001). Current Methods of the U.S. Preventive Services Task Force: A
Review of the Process. American Journal of Preventive Medicine, 20, 21-35.
To make safe and effective judgments using NANDA-I nursing diagnoses, it is essential
that nurses refer to the definitions and defining characteristics of the diagnoses listed
in Nursing Diagnoses: Definitions and Classification 20152017 2014, 2012, 2009,
2007, 2005, 2003, 1998, 1996, 1994 by NANDA International (ISBN 987-1-118-914939).
Copyright NANDA International, www.nanda.org Nursing Diagnoses: Definitions and Classification
2015-2017. 2014, 2012, 2009, 2007, 2005, 2003, 1998, 1996, 1994 by NANDA International,
Inc. Used by arrangement of John Wiley and Sons, Inc.

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Asthma

Revised: May 6, 2016

Chronic oxygen deficit

Altered level of consciousness

Behavioral changes (agitation, restlessness)

Changes in psychomotor activity

Difficulty initiating and/or following through with goal-directed or purposeful behavior

The patient will be free from injury.

The patient will participate in self-care activities.

The patient will be calm.

The patient will demonstrate stable neurologic status.

Assess for fall risk.

Assess the patients neurologic status every:

Assess vital signs every:

Assist in determining underlying cause of acute confusion, as indicated. Perform a

Ensure that dentures, glasses, and hearing aids are available.

Explain routines and changes in routines to the patient.

Have lighting follow normal sleep/wake patterns.

Provide aids to assist in orientation (clocks, calendar).

Reduce noise and environmental stimulation.

Reorient the patient as needed.

Administer medications, as prescribed, and assess response.

Continually monitor the patient as indicated by his condition.

Encourage family to visit the patient as appropriate.

Provide for consistency of staff in caring for the patient.

Treat the underlying condition as prescribed, and monitor for response.

The patient is free from injury.

The patient participates in his self-care activities.

The patient is calm and nonviolent.

The patient demonstrates stable neurologic status.

Acute or chronic illness

Altered attention span and concentration

Altered sleep habits

Altered vital signs

The patient will display decreased signs and symptoms of anxiety.

The patient will learn and demonstrate effective coping behaviors.

The patient will verbalize decreased anxiety.

The patients vital signs will be within the normal range.

Assess for signs and symptoms of anxiety.

Encourage the patient to verbalize his anxieties, concerns, and fears.

Help the patient identify factors that increase anxiety.

Provide care in a calm and reassuring manner.

Provide quiet time, and decrease environmental stimulation.

Teach stress reduction and relaxation techniques.

Use therapeutic communication skills to develop a trusting relationship with the

Administer medications, as prescribed, and monitor for effect.

Obtain referrals for counseling and therapy, as needed.

Provide therapies to reduce anxiety, such as music therapy.

Refer the patient to pastoral care, as appropriate.

The patient displays decreased signs and symptoms of anxiety.

The patient demonstrates effective coping behaviors.

The patient verbalizes decreased anxiety.

The patients vital signs are within the normal range.

Deficient Knowledge: Diagnostic Test

Difficulty remembering information

Lack of knowledge of resources

Inability to accurately follow instructions

Inability to recall information or demonstrate comprehension

Poor performance on a test of knowledge or return demonstration

Verbalization of insufficient knowledge

The patient will be able to verbalize follow-up procedures.

Assess for and reduce barriers to learning.

Assess the patients readiness to learn.