Nursing Care in clients with Asthma Bronchiale implemented through the nursing process approach, consisting of: Assessing, Diagnosing, Planning, Implementing, and Evaluating.
Nursing Assessment for Asthma Bronchiale : Signs and Symptoms
Basic assessment data :
Activity / Rest
- Symptoms: fatigue, malaise, inability to perform daily activities because of shortness of breath. Inability to sleep, need to sleep sitting up high. Dyspnea at rest or in response to activity or exercise
- Signs: fatigue, anxiety, insomnia, general weakness / loss of muscle mass.
Circulation
- Symptoms: swelling of the lower extremities.
- Signs: increase in blood pressure. Increased heart rate / severe tachycardia, dysrhythmias. Distended neck veins (severe disease). Dependent edema, unrelated to heart disease. Faint heart sounds (which is associated with increased AP diameter of the chest). Color of skin / membrane glucose: normal or gray / cyanosis: Nail clubbing and peripheral cyanosis. Pallor may indicate anemia.
Ego integrity
- Symptoms: increased risk factor. Changes in lifestyle.
- Signs: anxiety, fear, sensitive stimuli.
Food / fluid
- Symptoms: nausea / vomiting. Poor appetite / anorexia (emphysema). The inability to eat due to respiratory distress. Losing weight sedentary (emphysema), weight gain showed edema (bronchitis).
- Signs: poor skin turgor, dependent edema, sweating, weight loss, decreased muscle mass / fat subcutaneously (emphysema). Abdominal palpitation may declare hepatomegaly (bronchitis).
Hygiene
- Symptoms: decreased ability / enhancement needs doing daily activities.
- Signs: poor hygiene, body odor.
Breathing
- Symptoms: shortness of breath (onset hidden, with dyspnoea as a prominent symptom of emphysema), particularly in the workplace: the weather or recurrent episodes of difficult breathing (asthma): chest distress, inability to breathe (asthma). "Air Hunger 'chronic. Cough settled, with the production of sputum every day (especially when awake) for a minimum of 3 months in a row, every year at least 2 years, production of sputum (green, white, or yellow) can be a great deal (chronic bronchitis). Intermittent episodes of cough, usually is not productive at this early stage although it can be productive (emphysema). History of recurrent pneumonia, exposure to chemical pollution / fumes eg asbestos, coal dust, jute cotton, sawdust, family factors and oxygen at night or continuously.
- Signs: fast breathing, can be slow: lengthening the expiratory phase, with snoring, mouth breathing (emphysema). Preference for the three-point (Tripot) to breathe (especially with acute exacerbation of chronic bronchitis). The use of accessory muscles, eg raising the shoulders, retraction of supraclavicular fossa, widen the nose. hyperinflation of the chest can be seen quietly raising AP (shape-barrel): minimal diaphragm movement. Breath sounds: may dim with expiratory wheezing (emphysema): diffuse, soft or coarse moist crackles (bronchitis): crackles, wheezing in all lung areas on expiration, and the possibility for the inspiration to continue to decline or absence of wheezing (asthma). Percussion: hyper-resonant on the lung area (eg, air trap with emphysema): sound deaf in the area (eg, consolidation, fluid, mucosa). Difficulty speaking a sentence or more than 4 or 5 at a time. Color: pale with cyanotic lips and nail: gray Overall: red (chronic bronchitis "inflated blue '). Patients with emphysema were often called "pink fuffer" because skin color was normal despite normal gas exchange and rapid breathing frequency. Clubbing in the fingers (emphysema).
Security
- Symptoms: history of an allergic reaction or are sensitive to substances / environmental factors. The presence / recurrent infections. Redness / sweating (asthma).
Sexuality
- Symptoms: Decreased libido
Social interaction
- Symptoms: dependency relationship, lack of support systems, failure of support from family or significant others, long illness or incapacity improves.
- Signs: inability to create / maintain a sound, because respiratory distress. Physical mobility, abnormal relationships with other family members.
Counseling / Learning
- Symptoms: The use / abuse of drugs breathing, difficulty stopping smoking, regular alcohol use, failure to improve, repatriation planning considerations: the need for dental nursing, home care / home duties to maintain, change treatment / therapeutic program.