a. Auscultation of breath sounds, record the presence of breath sounds, such as: wheezing, ronkhi.
Rationale: Some degree of bronchial spasms occur with airway obstruction. Faint breath sounds with expiratory wheezing (empysema), there is no breathing function (severe asthma).
b. Review / monitor the frequency of recorded respiratory inspiration and expiration ratio.
Rational: Tachypnea is usually present in some degree and can be found at the reception during strest / presence of acute infectious process. Respiratory frequency can be slowed down and elongated than the expiration of inspiration.
c. Assess the patient to a safe position, such as: elevation head is not sitting on the backrest.
Rational: Elevation head is not easier for respiratory function by using gravity.
d. Observation of the characteristic cough, persistent, hacking cough, wet. Auxiliary measures to improve the effectiveness of cough effort.
Rational: cough may persist but are not effective, especially on elderly clients, acute pain / weakness.
e. Give warm water.
Rational: the use of warm fluids can decrease bronchial spasms.
f. Collaboration drugs as indicated.
Spiriva bronchodilator 1 × 1 (inhalation).
Rational: Freeing spasm of the airway, wheezing and mucus production.
http://blog-nursingcareplan.blogspot.com/2011/06/nursing-care-plan-for-asthma.html
