1. Definition Respiratory system are devide to external respiratory and internal respiratory.

The explanation are : External respiratory is the integrated system of organs involved in the intake and exchange of oxygen and carbon dioxide between an organism and the environment. . 2. Anatomy and Physiology 2.1 Cavity Nose Include the external nose protruding from the face and internal parts of the nasal cavity as a means of channeling the air. Outer nose covered by skin and supported by a pair of nasal bones. Nasal cavity consists of: * Vestibulum lined by submucosal cells as a protection * In the nasal cavity is the hair that acts as an air filter * Konka structure that serves as protection against the outside air because of the layered structure * Tues cilia that contribute to foreign bodies mlemparkan out in an attempt to clear the airway Internal parts berlorong nasal cavity which is separated into the right nasal cavity and left by a narrow vertical divider, called a septum. Each nasal cavity is divided into 3 channels by turbinasi or konka protrusion of the lateral wall. Nasal cavity lined with mucous membrane contains very many so-called vascular nasal mucosa. The secretion of mucus continuously by goblet cells that line the nasal mucosal surface and move to the back of the nasopharynx by the cilia movement. Nasal cavity starts from Vestibulum, namely in the anterior to the posterior part of which borders the nasopharynx. Nasal cavity is divided into 2 parts, namely Internal respiratory is metabolic process in the cell. This process hold in mitokondria and producted ATP

longitudinally by the nasal septum and the transverse by konka superior, medial, and inferior. Nose serves as a channel for air flow to and from the lungs. This airway function as a filter dirt and moisturizes and warms dihirupkan air into the lungs. Nose responsible for the olfactory receptors or penghidu because olfaksi located in the nasal mucosa. This function is reduced in line with age. There Nose spaces 3 functions, among others: a. In the case of breathing, inspired air through the nasal cavity will undergo the screening process tigs (filtration), heating, and pelembaban. Screening conducted by the mucous membranes in the nasal cavity is very rich in blood vessels and glands that secrete mucous serous liquid to clean the air before entering the Oropharynx. Heating performed by the network of blood vessels that are rich in nasal and ephitel cover a very wide area of the nasal cavity. And pelembaban done by Concha, which is an area of herniated discs which are covered by mucosa. b. Epithellium olfactory meial on the nasal cavity has a function in the sensation of odor reception. c. Nasal cavity was also associated with the formation of the voices fenotik where he serves as a resonance space. 2.2 Pharyngeal Pharynx is a funnel which has a length approximately 13 cm which connects nasal and oral cavity to the larynx at the base of the skull. Pharynx consists of: a. Nasopharinx * There liaison channel between nasopharinx the middle ear, the Tuba Tuba Eustachius and Auditory * There Phariyngeal tonsils (adenoids), located at the posterior part nasopharinx, is part of Lymphatic tissue on the posterior surface of the tongue

b. Oropharynx Is the center of the pharynx between the soft palate and hyoid bone. Swallowing reflex begins orofaring cause two changes, driven food into the digestive tract (oesephagus) and close the valves simultaneously larynx to prevent food into the respiratory tract. c. Laringopharynx Is the lowest position of the pharynx. At the bottom, a separate system of respiration digestil system. Food into the back, and air oesephagus forward into the larynx. 2.3 Larynx Larynx is composed of 9 Cartilago (6 Cartilago small and 3 large Cartilago). Biggest thyroid Cartilago shaped like a ship, the front protrusion formed through "adam's apple", and in this there cartilago vocal cords. Slightly below cartilago there cartilago cricoid thyroid. Laringopharynx connects the larynx with trachea, located at the anterior midline of the neck at cervical vertebrate 4 to 6. The main function of the larynx is to allow the occurrence of vocalizations. Larynx also protects the lower airway from foreign object obstruction and ease coughing. Larynx is often referred to as the voice box and consists of: a. Epiglotis: leaf valve os cartilage that covers the larynx during swallowing direction b. Glottis: os between the vocal cords in the larynx c. Thyroid cartilage: the largest cartilage of the trachea, a portion of this form the Adam's apple cartilage (Adam's Apple) d. Krikoid cartilage: the only complete ring of cartilage in the larynx (located beneath the thyroid cartilage) e. Cartilage Aritenoid: used in vocal cord movement with thyroid cartilage f. The vocal cords: the ligaments are controlled by muscle movement that generates the sound of voices; vocal cords attached to the lumen of the larynx.

There are 2 function is more important than the production of sound, namely: a. Larynx as a valve, closed during swallowing to prevent aspiration of liquids or solids into tracheobroncial b. Larynx as a valve during coughing 2.4 Trachea The trachea is a rigid channel length of 11-12 cm memeiliki with diametel approximately 2,5 cm. There on the outstretched oesephagus from cartilago cricoid into the thorax cavity. Composed of 16 to 20 ring-shaped cartilage of the letter "C" which opens at the back. Therein contained pseudostratified ciliated columnar epithelium with goblet cells that secrete mucus. There are also cilia which triggers a reflex cough / sneeze. Tracheal carina have branching formed on the left and right bronchus. 3. Causes, Signs and Symptoms 3.1 Causes : asthma the exact cause of asthma is not known. An asthma attack is a reaction to a trigger. It is similar to many ways to an allergic reaction. An allergic reaction is a response by the bodys immune system to an invader. When the cells of the immune system sense an invader, they set off the series of reactions that help fight off the invader. It is this series of reactions that cause the production of mucus and bronchospasms. These responses cause the symptoms of an asthma attack. In asthma, invaders are the triggers list below. triggers vary among individuals. Because asthma is a type of allergic reactions, it is sometimes called reactive airway disease.

Each person with asthma has his or her own unique set of triggers. Most triggers cause attacks in some people with asthma and not in others. Common triggers of asthma attacks are the following: exposure to tobacco or wood smoke, breathing polluted air, inhaling other respiratory irritants such as perfumes or cleaning products, exposure to airway irritants at the workplace, breathing in allergy-causing substances (allergens) such as molds, dust, or animal dander, an upper respiratory infection, such as a cold, flu, sinusitis, or bronchitis, exposure to cold, dry weather, emotional excitement or stress, physical exertion or exercise, reflux of stomach acid known as gastroesophageal reflux disease, or GERD, sulfites, an additive to some foods and wine, and menstruation: In some, not all, women, asthma symptoms are closely tied to the menstrual cycle. Risk factors for developing asthma: hay fever (allergic rhinitis) and other allergies -- this is the single biggest risk factor; eczema: another type of allergy affecting the skin; and genetic predisposition: a parent, brother, or sister also has asthma.

3.3 Sign :

Breathing changes Sneezing

Moodiness Headache Runny/stuffy nose Coughing Chin or throat itches Feeling tired Dark circles under eyes Trouble sleeping Poor tolerance for exercise Downward trend in peak flow number

3.2 Symptoms :

Shortness of breath, especially with exertion or at night Wheezing is a whistling or hissing sound when breathing out Coughing may be chronic, is usually worse at night and early morning, and may occur after exercise or when exposed to cold, dry air Chest tightness may occur with or without the above symptoms Severe coughing, wheezing, shortness of breath or tightness in the chest Difficulty talking or concentrating Walking causes shortness of breath Breathing may be shallow and fast or slower than usual Hunched shoulders (posturing)

Nasal flaring (nostril size increases with breathing) Neck area and between or below the ribs moves inward with breathing (retractions)

Gray or bluish tint to skin, beginning around the mouth (cyanosis) Peak flow numbers in the danger zone (usually below 50% of personal best)

4. Nursing Process 4.1 Assessment 4.1.1 Assesing Nursing / Illness History Patients Identity Chief Complain History of Present Illness Past Nursing History Family History Faktor Pencetus: Cigarette Emotional Disturbance Respiration Channel Infection Descent Dust Movement

4.1.2 Observation and PE (Physical Examination) Inspection Takipnea Terdengar mengi Pursed lip respiration Use the help muscle on respiration

Postur tubuh ke depan untuk membantu pernapasan Pernapasan cuping hidung Retraksi interkostal Sputum tebal dan lengket Ekspansi dada lateral menurun Palpation Retraksi interkostal Penurunan taktil fremitus Percussion Hiperresonansi Auscultation Pernapasan : bunyi napas jauh, fase ekspirasi memanjang, mengi selama respirasi Kardiovaskuler : takikardia, bunyi napas jauh 4.1.3 Diagnostic Test Peak Flow Peak Flow is probably the simplest test that you can use to see how well your asthma is doing and will be an integral part of your asthma care plan. Peak flows can easily be done at home with an inexpensive device called a peak flow meter. Peak flow measure how quickly air can be blown out of your lungs. Spirometry Spirometry is slightly more complicated than peak flow in that it is usually done in your doctors office and measures both how much and how quickly air moves out of your lungs. It is important in both the diagnosis and management of asthma over time.

Complete Pulmonary Function System Your asthma care provider may want to determine your lung volumes and

diffusing capacity. This is often done if your asthma diagnosis is unclear. The test requires you to sit inside a special box that helps determine how much air you breathe in and out. Lung Volumes: Your asthma care provider may order body

plethysmography test to determine your lung volumes. Asthma may cause certain changes in lung volumes that will assist your asthma care provider in diagnosing or treating your asthma. Diffusion Capacity: Diffusion capacity measures how well oxygen flows from the lungs into your blood. Poor diffusion indicates damage to the lung where the oxygen and blood meet in the lungs. Diffusion capacity is usually normal in asthmatics. Chest X-Ray A chest x-ray is a test commonly preformed for patients who wheeze. An asthma care provider will usually order one to make sure there is not some other condition that may be causing your symptoms like a lung infection. Pulse Oximetry Pulse oximetry is a non-invasive way to measure oxygenation of blood or how well oxygen is being exchanged between the lungs and the blood. A sensor is placed on the fingertip or other thin part of the body with blood vessels close to the skin. The sensor measures changes in wavelengths of light and is able to estimate oxygenation in the blood Allergy Testing

The relationship between allergies and asthma has been known for a long time. Allergens you normally breathe in can increase the inflammatory reaction and hyperresponsiveness in your lungs. However, your doctor cannot reliably determine if a particular allergen is responsible for your symptoms on clinical grounds alone. Because of this, your asthma care provider may recommend allergy testing. Not all asthmatics are tested. But if you have persistent asthma, your asthma care provider will probably recommend testing. Arterial Blood Gas An arterial blood gas (ABG) is an arterial blood sample used to determine how well blood is oxygenated a marker for oxygen exchange between the lungs and the blood. Commonly, a blood sample will be obtained from one of the arteries near your wrist. This test may likely be preformed during an acute asthma exacerbation and is more reliable than pulse oximetry. 4.2 Nursing Diagnosis 4.2.1 Problem: Allergy Etiology : Occurrence of allergy appears to be linked to various factors, including genetics (family predisposition) and environmental exposure, all leading to the same outcome. Typically the first exposure to an allergen sensitizes an individual. When subsequently exposed to allergens triggering hypersensitivity, leading to the degranulation of superficial mast cells and basophils. The affected mast cells and basophils then release mediators that lead to increased vascular permeability, tissue edema, and cellular recruitment. In addition to the influence of exogenous factors, endogenous factors influence the occurrence of allergy, as well. These influences include genetic factors, gender, race, and socioeconomic status, and prenatal and perinatal risk factors, including the month in which children are born (a higher incidence of asthma has been noted among children born in months of high pollen counts of grass, ragweed, birch, and mite allergens).

Many patients with asthma also need allergy skin tests to find out if the asthma is caused by inhaled pollen, molds, house dust, or animal danders which worsen the allergic reaction and inflammation in the lungs. Sign and symptoms: Sneezing, coughing, post nasal drip, respiratory arrest, noisy breathing, dyspnea, nasal erythema, nasal itching, nasal congestion, wheezing, edema of throat. 4.2.2 Problem : Anxiety

Etiology : Anxiety or panic attacks are characterized by surges of intense anxiety and fear that occur without warning and with no apparent reason. Panic attacks may be accompanied by sharp and abrupt chest pain, most likely caused by muscle contractions in the chest wall. The chest wall may feel sore for hours or days after a panic attack. Though easily treated with medication and relaxation techniques, anxiety and panic attacks can significantly disrupt an individual's life.

Sign and symptoms : Pale, cold, faintness, increased respiration, respiratory difficulties

4.2.3

Problem : Airway Obstruction

Etiology : Such partially irreversible airway obstruction may be due to residual airway inflammation, particularly of the ensinophilic type, and structural changes.

Sign and symptoms : Chest pain, irregular respiration, shallow respiration, changes in respiratory rhythm, adventitious breath sounds, diminished breath sounds, difficulty vocalizing, dyspnea, ineffective cough

4.2.4

Problem : Chest Pain

Etiology : Atypical chest pain is experienced outside the chest bone. It tends to be sudden, sharp and short-lived. The causes vary and may originate in the left chest, throat, shoulder, abdomen, back or arm. Atypical chest pain's causes include overexertion, spasms, acid indigestion and headaches. People with lower thresholds for pain are more likely to complain of atypical chest pain and are likely to have greater anxiety and depression.

Sign and symptoms : Pale, changes in respiratory rate

4.3 Intervention No. Nursing diagnosis 1. Allergy Goal statements (NOC) Long term goal: Will be Decrease Allergy Short term goal: Patient dont be fearness with that alergy Goal statement: 2. pengobatan segera infeksi bakteri pada pernafasan yang sukar Program pengobatan yang teratur dapat mengurangi kelabilan Intervention (NIC) 1. menghindari iritan Rationale Supaya pasien tidak terganggu dengan rasa elergi yang dideritanya.

sembuh.

bronkus cara efektif dan dengan demikian meninggikan ambang respon penyumbatan saluran nafas in order to patient to be comfortable .

2.

Anxiety

Long term goal: Will be decrease anxiety Short term goal: Patient can be relax,enjoy,and comfortable. Goal statement: Decrease fear and anxiety

1. maintain a calm, confident manner when interactiing with client 2. do not leave client alone during period of acute respiratory distress 3. perform actions to improve respiratory status in order to relieve dyspnea

In order to patient not to be alone .patient can be sharing .

Patient not be anxiety with dyspnea anywhere and anytime. Sputum characteristic shows as much as heavy the obstruction. Increase chest expantion Effective and controlled coughing can make excretion of mucus in airway easier.

3.

Airway obstruction Ineffective breathing patterns related to bronkhokonstriksi, bronkhospasm, edema mucus, bronchus wall and secretion congeal mucus.

Long term goal : effectively of airway. (Jalan nafas kembali efektif) Short term goal : Decrease dyspnoe, decrease counghing, airway clear of sputum, wheezing will be decrease/lost, normal vital sign. (Sesak berkurang, batuk

1. Asses colour, viscocity and how many sputum. 2. Arrange semifowler position 3. Teach how to do effective coughing

berkurang, klien dapat mengeluarkan sputum, wheezing berkurang/hilang, vital dalam batas normal keadaan umum baik.) 5. keep fluid intake to normal, minimally 2500 ml/days except there isnt indication. 6. colaboration in giving medicine. Broncodilator group B2 nebulizer (via inhalation) with terbulatine 0.25 mg, fenoterol HBr 0,1% solution, orcipenaline sulfur 0,75 mg. Intravena with theophyline ethilenediamine (Aminofilin) bolus IV 5-6 mg/kkBB 7. Mukolitic and expectorant agent. Mukolitic agent increase secret The purpose of giving by intravena to keep optimal airway dilatation. Broncodilator via inhalation will enter bronchus area with spasm directly, so there is dilatation quickly. 4. train client to nafas dalam Maximal ventilation open airway lumen and increase secret activity to take out by high airway Strong hidration will help to dilute secret and effective cleaning the airway.

viscositiness and adhesiveness in lung to clean airway easier. Expectorant will make 4. Chest pain Related with the enlarge respiratory tract Long term goal : Chest pain will be lost after nursing care Short term goal : Chest pain will be lost after 24 hours, the client can demonstrate relaxation technique Goal statement: The client is relax and never complain about the pain

Evaluation