Question

Prioritise your first three (3) nursing interventions after the primary survey. These interventions may include the administration of nurse initiated medications, escalation of care, and/or further assessments. Provide a rationale for theinterventions that clearly demonstrate how the intervention will address the underlying pathophysiology of asthma and how the intervention is supported by the evidence.

Answer 1

Asthma

A long term respiratory condition, in which the airways may unexpectedly and suddenly narrow, often in response to an allergen , cold air , excersie or emotional stress. Symptoms include wheezing , shortness of breath, chest tightness and coughing.

Nursing Interventions:( with rationale)

1. Assessment:

The basic nursing asessment should prerform , such as:

* Asess the history of the patient ( Medical and surgical, any allergy , especially to drugs): to get a baseline information about the client and allegic responses

*monitoring the vital signs and pulse oximetry : to get base line data and to know the oxygen saturation in the blood. ( 95% - 100 considered as normal)

-Assess respiratory status,rate , depth and beath sounds ;for any abnormal breath sounds like wheezing or stridor.

Wheezing happens due to bronchospasm

stridor is harsh, shrill , unpleasant sound. It is a high pitched wheezing sound occurs in Severe asthma.

2. Provide a comfortable position with head end of the bed elevated:

Semi Fowler's position or Fowler's position helps to expand the chest volume by relaxing the abdominal muscles , makes the lungs to expand easily.

3. Administer Medications as per Doctor's order

Albuterol or Terbutaline : are bronchodialators, that relax muscle lining of the bronchioles, thus dialate the airways for easy breathing.

Budesonide or Fluticasone: are Corticosteroids , that helps to reduce the inflammation , there by reducing the swelling and mucous of the airways.