Care Plan

1059 Words5 Pages
• Nursing Diagnosis Ineffective breathing pattern related to anxiety and inflammation of upper airways (due to upper respiratory tract infection) as evidenced by dyspnoea, tachypnoea, orthopnoea, using accessory muscle, prolonged expiratory phase 1:3, wheezing, speaking in phrase only, sitting upright body position, PEFR 58% below personal best. • How signs and symptoms indicate Mia’s ineffective breathing pattern Ms Bao Tran Nguyen (Mia) suffers dyspnoea and tachypnoea due to airway obstruction in response to inflammation (Porth, 1998). Because of fragmented speech, which she speaks in phrases before taking a breath, nurses can aware of ineffective breathing pattern. Mia’s respiratory rate is 30 which sharply increased than normal range that is 12 to 20. Furthermore, because of progressive airway obstruction, her expiration becomes prolonged. Despite a normal inspiratory: expiratory ratio of 1:2, but hers 1:3 so it indicates that her breathing pattern is ineffective. Audible wheezing is presented in Mia’s breathing that indicates her airways become narrower than usual (Brown and Edwards, 2008). In addition, more energy is needed to overcome the tension already present in the airway, so she is sitting upright and using accessory muscles to maintain ventilation. Mia’s peak expiratory flow rate (PEFR), which is 58% below personal best, also shows that she has ineffective breathing. A fall in the PEFR to levels below 25% of the personal best during an acute asthmatic attack suggests respiratory failure (Porth, 1998). • Pathophysiological process of Asthma Asthma is a chronic inflammatory disorder of the airways. This inflammation causes airway hyperresponsiveness which is caused by bronchoconstriction in response to physical, chemical and pharmacological agents. When mast cells become activated, by stimuli such as allergens, irritants and infections,

More about Care Plan

Open Document