DataEtiologiMasalah keperawatan

DS: Tn. Cungkring merasa susah napas/ abnormal breathing sakit kepala/ headache diaforesis/ diaphoresis

DO: Pernapasan cuping hidung/ Nasal flaring pernapasan abnormal / abnormal breathing rate 27x/menit BTA (basil tahan asam) (+) - penurunan carbon dioksida/ decreased carbon dioxide PCO2 49mmHgPerubahan membrane alveolar kapiler b.d gangguan pertukaran gas (Alveolar apillary membrane changes r.w impaired gas exchange)Impiared Gas Exchange(00030)Domain : 3 Elimination and ExchangeClass : 4 Respiratory function

Axis I : pertukaran gas Axis II : IndividuAxis III: impairedAxis IV: kardiopulmonalAxis V : dewasa Axis VI : akutAxis VII : actual

Data Etiologi Maslah keperawatan

DS: Tn. Cungkring merasa susah napas

DO : Pernapasan cuping hidung Perubahan frekuensi napas (27x/menit) Batuk tidak efektif /ineffective cough Sputum dalam jumlah yang berlebih / Excessive sputum (lender kental , kuning kehijauan , terkadang disertai bercak darah)Environmental : SmokingObstructed Airway : foreign body in airwayPhysiological : Chronic obstructive pulmonary (penyakit paru obstruksi kronis b.d ketidak efektifan bersihan jalan nafas / ineffective airway clearance) Ineffective airway clearance(00031)Domain : 11 safety / protectionClass : 2 physical injury

Axis I : perttukaran gasAxis II : IndividuAxis III: ineffectiveAxis IV: kardiopulmonalAxis V : dewasa Axis VI : akutAxis VII : actual

Data Etiologi Masalah keperawatan

DS: Tn. Cungkring merasa susah napas Fatique Malaise Diaphoresis

DO: Pernapasan cuping hidung / nasal flaring Penggunaan otot aksesoris / use of accessory muscles to breatheKeletihan otot pernapasan / respiratory muscle fatiqueb.d ineffective breathing pattern Ineffective breathing pattern (00032)Domain : 4 Activity / restClass : 4 cardiovascular / pulmonary responses

Axis I : perttukaran gasAxis II : IndividuAxis III: ineffectiveAxis IV: kardiopulmonalAxis V : dewasa Axis VI : akutAxis VII : actual

Data Etiologi Masalah keperawatan

DO: Body weigh 20% or more below ideal weight range (berat badan 20% atau lebih di bawah berat badan ideal) Lack of food (kurang makan) Rumah Tn, Cungkring 5x6 meter ,ventilasi hanya berasal dari satu pintu ,lingkungan lembab, lantai dari tananh, atab terbuat dari asbes, dan kegiatan memasak dilakukan di ruangan tersebut dengan peralatan minimal.

Insufficient finances r.w imbalanced nutrition less than body requirements(ketidak seimbangan nutrisi kurang dari kebutuhan tubuh b.d factor ekonomi Imbalanced nutrition less than body requirements (00002)Domain : 2 NutritionClass: 1 ingestion

Axis I : nutritionAxis II : IndividuAxis III: imbalanced Axis IV: gastrointestinalAxis V : dewasa Axis VI : akutAxis VII : actual

No . prioritas Kode diagnose Diagnose keperawatan Tanggal muncul Tanggal teratasi

100030Impaired gas exchange , individu, pulmonary, dewasa ,akut, actual, b.d perubahan memebran alveolar ditandai dengan pasien merasa susah nafas, sakit kepala ,diaphoresis, pernafasan cuping hidung,RR=27x/menit , BTA (+) , penurunan pCO2 =49 mmHg01/10/2012

200031Ineffective airway clearance , individu, pulmonary ,dewasa, akut, actual, b.d (merokok, materi asing dalam jalan nafas, penyakit paru obstruksi kronis ) ditandai dengan dengan pasien merasa susah napas (RR=27x/menit) ,pernapasan cuping hidung, batuk tidak efektif, sputum dalam jumlah berlebih(lender kental, kuning kehijauan,terkadang disertai bercak darah)

300032Ineffective brething pattern , individu, pulmonary, dewasa,akut,actual b.d keletihan otot pernapasan ditandai dengan pasien merasa susah napas (RR=27x/menit),fatique ,malaise, diaphoresis,pernapasan cuping hidung, penggunaan otot aksesories untuk bernapas

400002Imbalanced nutrition less than body requirements ,individu ,gastrointestinal , dewasa, akut, actual b.d factor ekonomi ditandai dengan berat badan 20% atau lebih di bawah berat badan ideal ,kurang makan , Rumah Tn, Cungkring 5x6 meter ,ventilasi hanya berasal dari satu pintu ,lingkungan lembab, lantai dari tananh, atab terbuat dari asbes, dan kegiatan memasak dilakukan di ruangan tersebut dengan peralatan minimal.

NOCTaxonomy of Nursing outcome Level 1Domain (2) domain II .-Physiologic HealthOutcomes that describe organic functioning

Level 2ClassesE- Cardiopulmonary Outcomes that describe an individuals cardiac,pulmonary, circulatory, or tissue perfusion status

Level 3outcomes0415040204030408Respiratory status Respiratory status : gas exchange Respiratory status : ventilationTissue perfusion : pulmonary

No . prioritas Kode diagnose NOC (Nusrsing outcome classification )

100030Gas Exchange : impaired / gangguan pertukaran gas Definition : excess of deficit in oxygenation and / or carbon dioxide elimination at the alveolar capillary membrane .(kelebihan dan kekurangan atau eliminasi karbondiosida di membrane capilar-alveolar.)

Suggested outcomes: Acute confution level Respiratory status Respiratory status : gas exchange Respiratory status : ventilation Tissue perfution : pulmonary Vital signs

Outcome target ranting :Respiratory status ----0415

INDICATOR:

Serve 1Substantial2Moderate 3Mild 4No 5

041501041502041509041510041518041528041531Respiratory rateRespiratory rhythmOxygen saturationAccessory muscle use Diaphoresis Nasal flaring Coughing

Respiratory status : Gas Exchange ----0402

INDICATOR:

Serve 1Substantial2Moderate 3Mild 4No 5

040208

040209

040213

Partial pressure of oxygen in arterial blood (PaO2)Partial pressure of carbon dioxide in arterial blood (PaCO2)Chest x-ray findings

Respiratory status : ventilation ----0403

INDICATOR:

Serve 1Substantial2Moderate 3Mild 4No 5

040311040331 Chest retractionAccumulation of sputum

Tissue perfusion : pulmonary ----0408

INDICATOR:

Serve 1Substantial2Moderate 3Mild 4No 5

040820040805040824 Arterial PHChest pain Impaired gas exchange

NICTaxonomy of Nursing Interfentations,Level 1Domain2. Physiological : comlex-contdCare that support homeostatic regulation

Level 2ClassesK. Respiratory manajement Interventions to promote airway patency and gas exchange

Level 3 Interventions3140325031603230332033508880Airway manajementCough enhancement3Airway suctioningChest physiotherapyOxygen therapyRespiratory monitoringEnvironmental risk protection

Level 1Domain7Community Care that supports the health of the community

Level 2ClassesC.Community risk management : interfention that assist in detecting or preventing health , risks to the whole community

Level 3 Interventions8880

Environmental risk protection

The Classification,Domain ClassesInterventions

2Physiological : comlex-contdCare that support homeostatic regulationKRespiratory manajement Interventions to promote airway patency and gas exchange3140Airway manajementDefinition : facilitation of patency of air passage

Activities: Open the airway, using the chin lift or jaw thrust technique, as appropriate Position patient to maximize ventilation potential Identify patient requiring actual/potential airway insertion Insert oral or nasopharyngeal airway, as apporopriate Perform chest physical therapy, as appropriate Remove secretion by encouraging coughing or sactioning Encourageslow,deep breathing; turning; and coughing Use fun techniques to encourage deep breathing for children (e,g., blow bubbles with bubble blower; blow on pinwheel, whistle, harmonica, balloons, party blowers; have contest using ping-pong balls,feathers) Instruct how to cough effectively Assist with incentive spirometer, as appropriate Auscultate breath sounds, noting areas of descreased or absent ventilation and presence of adventitious sounds Perform endotraceal or nasotracheal suctioning, as appropriate Administer brocodilators, as approoriate Teach patient how to use prescribed inhalers, as appropriate Administer aerosol treatments, as appropriate Administer ultrasonic nebulizer treatment, as appropriate Administer humidified air or oxygen, as appropriate Remove foreign bodies with Mcgill forceps, as appropriate Regulate fluid intake to optimize fluid balance Position to alleviate dyspnea Monitor respiratory and oxygenation status, as appropriate1st edition 1992; revised 3rd edition 2000; revised 4th edition 2004

Backround Readings:American Association of critical-Care Nurses. (1998). Core curriculum for critical care nursing (5th ed.). St. Louis. MO: Mosby.Racht, E. M. (2002). 10 pitfalls in airway management: How to avoid common airway management complications.Jems: journal of emergency Mrdical Services,27(3), 28-34, 36-38, 40-42.

Domain ClassesInterventions

2Physiological : comlex-contdCare that support homeostatic regulationKRespiratory manajement Interventions to promote airway patency and gas exchange3250Cough enhancementDefinition: promotion of deep inhalation by the patient with subsequent generation of high intratoracic pressures and compression of underlying dung parenching for the forceftil expulsion of air.

Activities: Monitor results of pulmonary function tests, particulary vital capacity, maximal inspiratory force, forced expiratory volume in 1 second (FEV1), and FEV1/FVC, as appropriate Assist patient to a sitting position with head slightly flexed, shoulders relaxed, and knees flexed Encourage patient to take several deep breaths Encourage patient to take a deep breath, hold it for 2 seconds, and cough two or three times in succession Instruct patient to inhale deeply, bend forward slightly, and perform three or four huffs (against an open glottis) Instruct patient to inhale deeply several times, to exhale slowly, and to cough at the end of exhalation Initiate lateral chest wall rib spring techniques during the expiration phase of the cough maneuver, as appropriate Compress abdomen below the xiphoid with the flat hand, while assisting the patient to flex forward as the patient coughs Instruct patient to follow coughing with several maximal inhalation breaths Encourage use of incentive spirometry, as appropriate Promote systemic fluid hydration, as appropriate Assist patient to use a pillow or rolled blanket as a splint against incision when couhing

1st edition 1992; revised 4th edition 2004

Background readings;Perry, A. G., & Potter, P. A. (2002). Clinical nursing skills and technique (5th ed.). St. Louis, MO: Mosby.Thelan, L. A., & Urden, L. D. (1993). Critical care nursing: Diagnosis and management (2nd ed.). St. Louis, MO: Mosby

Domain ClassesInterventions

2Physiological : comlex-contdCare that support homeostatic regulationKRespiratory manajement Interventions to promote airway patency and gas exchange3160Airway suctioningDefinition: removal of airway secretion by inserting a suction catheter into the patiens oral into infron of trachea.

Acthivities : Determine the need for oral and or tracheal suctioning Auscultate breath sounds before and after suchtioning Inform the patient and family about suchtioning Aspirate the nasopharynx with a buld syringe or suction device,as appropriate Provide sedation, as appropriate Use universal precaution : gloves,goggles,and mask, as appropriate Insert a nasal airway to facilitate nasotracheal suchtioning,as approphriate Instruct the patient to take several deep breaths before nasotracheal suctioning and use supplemental oxy-gen as appropriate Hyperoksigenate with 100% axygen, using the ventilator or manual resuctitation bag Hyperinflate at 1 to 1,5 times the preset tidal volume using the mechanical ventilator, as appropriate Use sterile disposable equitment for each tracheal suction procedure Select a saction catheter that is one half the internal diameter of the endotracheal tube, traceostomy tube, of patients airway Instruct the patient to take slow, deep breaths during insertion of the suction catheter via the nasotracheal route Leave the patient connected to the ventilator during sactioning, if a closed tracheal saction system or an oxy-gen insufflation device adaptor is being used Use the lowest amount of wall saction necessary to remove secretions (e.g., 80 to 100 mmHg for adults) Monitor patients oxygen status (SaO2 and SvO2 levels) and hemodynamic status (MAP level and cardiac rhythms) immediately before, during, and after sactioning Base the duration of each tracheal suction pass on the necessity to remove secretions and the patients response to sactioning Hyperinflate and hyperoxygenate between each tracheal suction pass and after the final suction pass Suction the orapharynx after completion of tracheal suctioning Clean area around tracheal stoma after completion of tracheal sactioning, as appropriate Stop tracheal suctioning and provide supplemental oxygen if patient experiences bradycardia, an increase in ventricular ectopy, and/or desaturation Vary suctioning techniques, based on the clinical response of the patient Note type and amount of secretions obtained Send secretions for culture and sensitivity tests, as appropriate Instruct the patient and/or family how to suction the airway, as appropriate1st edition 1992

Background readings:Barnes,C., & Kirchhoff, K. T. (1986). Minimizinghypoxemia due to endotracheal suctioning: A review of the literar\ture.Heart & Lung, 15(2),164-176.Craven, R. F., & Hirnle, C.J. (2000). Fundamentals of nursing: Human health and function. (3rd ed.). (pp. 825-827). Philadelphia:Lippincott Williams & Wilkins.

Domain ClassesInterventions

2Physiological : comlex-contdCare that support homeostatic regulationKRespiratory manajement Interventions to promote airway patency and gas exchange3230Chest physiotherapyDefinition : assisting the patient to move airway secretions from peripheral air way to more central airways for expectoration /or suctioning

Activities: Determine presence of contraindications for use of chest physical therapy Determine which lung segment(s) to be drained in uppermost position Use pillows to support patient in designated position Use percussion with postural drainage by cupping hands and clapping the chest wall in rapid succession to produce a series of hollow sounds Use chest vibration in combination with postural drainage , as appropriate Use ultrasonic nebulizer , as appropriate Use aerosol theraphy, as appropriate Administer bronchodilarors , as appropriate Monitor amount and type of sputum expectoration Encourage coughing during and after postural drainage Monitoring patient tolerance via SaO2, respiratory rhythm and rate ,cardiac rhytm and rate, and comfort levels1st edition 1992

Background radings:Brooks-Brunn, J.(1986). Respiration. In L. abels (Ed.), Critical care nursing: A physiologic approach (pp.168-253). St. Louis, MO: Mosby.Craven, R F., & Himle , C.J. (2000). Fundamental of Nursing: human health fungtion (3rd ed,). (pp. 810-813). Philadelphia: Lippincott Williams & Wilkins.Kiriloff, L. H., Owens, G. R., Rogers, R. M. & Mazzocco, M. C. (1985). Does chest physical therapy work? Chest, 88(3), 436-444Nelson, D M. (1992). Intervention related to respiratory care . in G. M Bulechek & J.C McCloskey (Eds.), Symposium on nursing interventions: Nursing Clinics of North America , 27(2), 301-324Smeltzer, S.C .,& Bare, B. G. (2004). Brunner&Suddarths textbook of medical surgical nursing, (Vol. 2.) (10th ed,). Philadelphia: Lippincott Williams & Wilkins.Sutton, P., Parker, R., Webber, B., Newman, S., Garland , N., Lapez-Vindriera, M., D & Clark, S. W (1983). Assesment of the forced expiration thecnique, postural drainage, and diregted coughing in chest physiotherapy. European Jurnal of Respiratory Disease, 64(1)62-68.

Domain ClassesInterventions

2Physiological : comlex-contdCare that support homeostatic regulationKRespiratory manajement Interventions to promote airway patency and gas exchange3320Oxygen therapyDefinition : administration of oxygen and monitoring of its effectiveness

Activities: Clear oral, nasal, and tracheal secretions, as appropriate Restrict smoking Maintain airway patency Set up oxygen equipment and administer through a heated, humidified system Administer supplemental oxygen as ordered Monitor the oxygen liter flow Monitor position of oxygen delivery device Instruct patient about importance of leaving oxygen delivery device on Periodically check oxygen delivery device to ensure that the prescribed concentration is being delivered Monitor the effectiveness of oxygen therapy (e.g., pulse oximetry, ABGs), as appropriate Assure replacement of oxygen mask/cannula whenever the device is removed Monitor patients ability to tolerate removal of oxygen while eating Change oxygen delivery device from mask to nasal prongs during meals, as tolerated Observe for signs of oxygen-induced hypoventilation Monitor for signs of oxygen toxicity and absorption atelectasis Monitor oxygen equipment to ensure that it is not interfering with the patients attempts to breathe Monitor patients anxiety related to need for oxygen therapy Monitor for skin breakdown from friction of oxygen device Provide for oxygen when patient is transported Instruct patient to obtain a supplementary oxygen prescription before air travel or trips to high altitude, as appropriate Consult with other health care personnel regarding use of supplemental oxygen during activity and/or sleep Instruct patient and family about use of oxygen at home Arrange for use of oxygen devices that facilitate mobility and teach patient accordingly Convert to alternate oxygen delivery device to promote comfort, as appropriate

1st edition 1992; revised 3rd edition 2000

Background readings:American association of critical care nurses. (2006). Care curriculum for critical care nursing (6th ed.) [J. G. Alspach, Ed]. Philadelphia: W. B. Saunders.Gottlie, B. J. (1998). Breathing ang gas exchange. In M. Kinney, D. Packa, & S. Dunbar (Eds.), AACNs clinical reference for critical-care nursing (2nd ed.) (pp. 160-192). St. Louis, MO:Mosby.Lewis, S. M., & Collies, I. C. (1996). Medical-surgical nursing: assement and management of clinical problems (4th ed.) St. Louis, MO: MosbyNelson, D. M. (1992). Interventions related to respiratory care. In G. M. Bulechek & J. C. McCloskey (Eds.), symposium on nursing interventions. Nursing clinics of north america, 27(2), 301-323Suddarth, D. (1991). The lippincott manual of nursing practice (5th ed.) (pp. 210-226). Philadelphia: J. B. LippincottThelan, L. A., & Urden, L. D. (1998). Critical care nursing: diagnosis and management (3rd ed.). st. Louis, MO:Mosbyu.S. department of health and human services. (1994). Unstable angina: Diagnosis and management. Rockville, MD: Agency for health care policy and research.

Domain ClassesInterventions

2Physiological : comlex-contdCare that support homeostatic regulationKRespiratory manajement Interventions to promote airway patency and gas exchange3350Respiratory monitoringDefinition : collection and analysis of patien data to ensure air way patency and adequate gas excange

Activities : Monitor rate, rhythm, depth and effort of respiration Note chest movement, watching for symmetry, use of accesory muscles, and supraclavicular, and intercostal musle retraktion Monitor for noisy respiration, such as crowing or snoring. Monitor breathing patterns: bradipnea, tachypnea, hyperventilation, kussmaul respiration, cheyne stokes, respiration, apneustic, biots respiration,and ataxic pattern Palpate for equal lung expansion Percus anterior and posterior thorax from apices to bases bilaterally Note location of trachea Monitor for diaphragmatic muscle fatigue Auscultate breath sounds, noting areas of decreased / absent ventilation and presence of adventitious sounds Determine the need for suctioning by austultating for crackle and ronchi over major airways Auscultate lung sounds after treatmens to note result Monitor PFT values, particularly vital capasity, maximal inspiratory force, forced expiratory volume in 1 second (FEV 1), and FEV/FVC as available Monitor mecanical ventilator readings, noting increases in inspiratory pressures and decreases in tidal volume as appropiate Monitor for increased retlessness, anxiety, and air hunger Note changes in SaO2, SvO2, and tidal CO2, and changes in ABG values, as appropiate Monitor pattients ability to cough effectively Note onset, characteristic, and duration chough. Monitor patients respiratory secretion. Note onset,characterics,and duration of cough Monitor patients rescretions Monitor for dyspnea and events that inprove and worsen it Monitor forhoarseness and voice changes every hour in patients with facial burns Monitor for chest x-ray reports Open the patient on side, as indicated, to prevent aspiration; logroll if cervical aspiration suspected Institute resuscitation efforts, as needed Institute respiratory therapy treatments (e.g., nebulizer), as needed

Domain ClassesInterventions

7Community Care that supports the health of the communityCCommunity risk management : interfention that assist in detecting or preventing health , risks to the whole community 8880Environmental risk protection Definition: preventing and detecting disease and injury in populations at risk from environmental hazard

Activities: Assess environtment for potential and actual risk Analyze the level of risk associated with the environment (e,g., living habits, work, atsmosphere, water housing,food, waste, radiation, and violence) Inform population at risk about the environmental hazart Monitor incident of illness and injury related to environment standart (e.g., environment protection agency (EPA) and occupation safety and health administration (OSHA) regulation.) Notify agencies authorized to protect to improve environmental safety Collaborate with other agencies to improve environmental safety Advocate for safer environmental designs , protection systems, and use of protective devices Support programs to disclose environment hazards Screen population at risk for evidence of exposure to environment hazards Participate in data collection related to incidence of exposure to environmental hazards