Diagnosa Keperawatan : 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Resiko Cidera Gangguan Persepsi Sensori Gangguan Citra Tubuh Gangguan Menelan Ketidakefektifan Pola Napas Gangguan Pertukaran Gas Ketidakefektifan Bersihan Jalan Napas Gangguan Komunikasi Verbal Hambatan Mobilitas Fisik Nyeri Mual

Prioritas Masalah : 1. 2. Ketidakefektifan Bersihan Jalan Napas Ketidakefektifan Pola Napas

NIC NOC Diagnosa Keperawatan 1. Ketidakefektifan Bersihan Jalan Napas NIC : Activities : 1. 2. 3. Determine the need for oral and/or tracheal suctioning Auscultate breath sounds before and after suctioning Inform the patient and family abaout suctioning

4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24.

Aspirate the nasopharynx, with a bulb syringe or suction device, as appropriate Provide sedation, as appropriate Use universal precautions gloves, glogges, and mask , as appropriate Insert a nasal airway to facilitate nasotracheal suctioning, as appropriate Instruct the patient to take several deep breaths before nasotracheal suctioning and the use supplemental oxygen, as appropriate Hyperoxygenate with 100% oxygen, using the ventilator or manual resusitation bag Use sterile disposable equipment for each tracheal suction procedure Select a suction catheter that is one half the internal diameter of the endotracheal tube, tracheostomy tube or patients airway Instruct patient to take slow , deep breaths during insertion of the suction catheter via the nasotracheal route Leave the patient connected to the ventilator during suctioning. If a closed tracheal suction system or an oxygen insufflation device adaptor is being used. Use the lowest amount of wall suction necessary to remove secretions (e.g. 80 to 100 mmHg for adults) Monitor patients oxygens status (SaO2 and SvO2 levels) and hemodynamic status (MAP level and cardiac rhytms) immediately before, during and after suctioning Base the duration of each tracheal suction pass on the incressity to remove secretions and patients respone to suctioning Hyperinflate and hyperoxygenate beetwen each tracheal suction pass and after the final suction pass Suction the oropharynx after completion of tracheal suctioning Clean area around tracheal stoma after completion of tracheal suctioning, as appropriate Stop tracheal suctioning and provide supplemental oxygen if patient experiences brachycardia in increase in ventricular octops and/or desaturation Vary suctioning techniques, based on the clinical response of the patient Note type and amount of secretion obtained Send secretion for culture and sensitivity test, as appropriate Instruct the patient and/or family how to suction the airway, as appropriate

NOC Respiratory status : Airway Patency (0410) Domain Physiologic Health ( II) Class Cardiopulmonary (E) Scale Extremely compromised to Not compromised (a) Definition : extent to which the tracheo brochial passages remain open Respiratory status : Airway patency Indicators 041001 041002 041003 041004 041005 041006 041007 041008 Fever not present Anxiety not present Choking not present Respiratory rate IER Respiratory rhythm IER Move sputum out of airway Free of adventitious breath sounds Other ................
(specity)

Extremely compromised 1

Substantially compromised 2

Moderately Compromised 3

Mildly Compromised 4

Not compromised 5

1 1 1 1 1 1 1

2 2 2 2 2 2 2

3 3 3 3 3 3 3

4 4 4 4 4 4 4

5 5 5 5 5 5 5

25.

IER : In Expected Range

2. Ketidakefektifan Pola Napas NIC : Activities : 1. 2. 3. 4. Monitor rate, rhythm, depth, and effort of respirations Note chest movement, watching for symmetry use of accesory muscles, and supractivicular and intercostal muscle retractions Monitor of noisy respiration, such as crowing or snoring Monitor breathing patterns : tachtpnea, hyperventilation, kussmaul respirations, cheyne stokes respirations, apneustic breathing, biots respiration and ataxic patterns 5. Palpate for equal lung expansion 6. Percuss anterior and posterior thorax from apices to bases bilaterally 7. Note location of trachea 8. Monitor for diaphragmatic muscle fatigue (paradoxical motion) 9. Auscultate breath sounds, nothing areas of decreased/ absent ventilation and presence of adventitious sounds 10. Determine the need for suctioning by auscultating for crackles and rhonchi over major airways 11. Auscultate lang sounds after treatment to note result 12. Monitor PFT values, particularly vital capacity, maximal inspiratory force, forced expiratory volume in 1 second (FEV1), and FEV1 / FVC, as available 13. Monitor mechanical ventilator readings, nothing increase in inspiratory pressures and decrease in tidal volume, as appropriate 14. Monitor for increased restlessnes, anxiety, and air hunger 15. Note changes in SaO2, SvO2, end-tidal CO2, and ABG values, as appropriate 16. Monitor patients ability to cough effectively 17. Note onset, charcteristics, and duration of cough 18. Monitor patients respiratory secretions 19. Monitor for dypsnea and events that decrease and worsen it 20. Monitor for hoarseness and voice changes every hour in patient with facial burns 21. Monitor for crepitus, as appropriate 22. Monitor chest x-ray reports

23. Open the airway, using the chin lift or jaw thurst technique, as appropriate 24. Place the patient on sude, as indicated, to prevent aspiration; log roll if cervical aspiration is suspected 25. Institute resuscitation efforts, ass needed 26. Institute respiratory therapy treatmrnts (e.g. nebulizer), as needed.

NOC Respiratory Status : Ventilation (0403) Domain Physiologic Health ( II) Class Cardiopulmonary (E) Scale Extremely compromised to Not compromised (a) Definition : movement of air in and out of the lungs Respiratory status : Airway patency Indicators 040301 040302 040303 040304 040305 Respiratory rate IER Respiratory rhythm IER Depth of inspiration Chest expansion symmetrical Ease of breathing 1 1 1 1 1 2 2 2 2 2 2 3 3 3 3 3 3 4 4 4 4 4 4 5 5 5 5 5 5 Extremely compromised 1 Substantially compromised 2 Moderately Compromised 3 Mildly Compromised 4 Not compromised 5

040306 040307 040308

Move sputum out of airway Vocalizes adequately Expulsion of air

1 2 1 1 2 3 4 5 3 4 5

040309 040310 040311 040312

040313 040314 040315 040316 040317 040318 040319 040320 040321

Accessory muscle use not present Adventitious breath sound not present Chest retraction not present Pursed lips breathing not present Dypsnea at rest not present Dypsnea with exertion not present Orthopnea not present SOB not present Tactile fremitus not present Percussed sounds IER Ausculated breath sounds IER Ausculated vocalization IER Bronchophony IER

1 1 1 1

2 2 2 2

3 3 3 3 3

4 4 4 4 4

5 5 5 5 5

1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3

4 4 4 4 4 4 4 4 4

5 5 5 5 5 5 5 5 5

040322 040323 040324 040325

Egophony IER Whispered pectoriloquy IER Tidal volume IER Vital capacity IER

1 1 1 1

2 2 2 2

3 3 3 3

4 4 4 4

5 5 5 5

040326 040327

Chest X-ray findings IER Pulmonary function test IER Other ................
(specity)

1 1

2 2

3 3

4 4

5 5

040328

IER : In Expected Range; SOB : Shortness Of Breath

Daftar pustaka Johnson, Marion., Maas, Meridean dan Moorhead, Sue. 2000. Nursing Outcomes Classification (NOC). Edition : 2nd. USA : Mosby, Inc Dochterman, JM. Bulechek, GM. 2004. Nursing Interventions Classification (NIC). Edition : 4th.USA : Mosby. Inc