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Nursing Care On NN.T With Bronchitis Flamboyan 3 Room General Hospital Salatiga
Nursing Care On NN.T With Bronchitis Flamboyan 3 Room General Hospital Salatiga
Compiled by:
I.
II.
No
1
Rational
1.For
monitoring
respiration
and oxygen
status.
2.for
breathing to
be more
smoothly.
3.for more
relaxed and
more
comfortable
.
4.for
reducing
shortness of
breath.
Signature
Desi
III.
Can prevent
the factors
that block
the airway.
As there is
no retained
secretions.
DATA ANALYSIS
Name
: Nn. s
No.CM
Age
: 23 years
IV.
: 0605-2203
Problem
Etiology
signature
Airway
airway
Desi
clearance
obstruction.
ineffectiveness
Name
: Nn. s
No.CM
Age
: 23 years
Date/hours No Implementation
: 0605-2203
Client Response
Signature
*Subjective data:
Desi
Dx
Saturday
10 January
th
2015
09.00 pm
*Airway Management
(3140)
1. monitor respiration and
oxygen status
Pasien said
shortness of breath
*objective data:
-irregular breathing
-patients seem
attached to the 4
liter oxygen
09.15 pm
*Subjective data:
Desi
09.45 pm
*Subjective data:
10.10 pm
4.perform
oxygen therapy as
needed *Subjective
data:
*objective data:
Patient is willing to
be taught deep
breathing relaxation
Desi
*objective data:
Patient seem to
follow instructions
while performing
deep breathing
relaxation
4.perform oxygen therapy
as needed
*Subjective data:
Patient said willing
to be given oxygen,
because it felt the
breath
*objective data:
-patient is attached
to the oxygen nasal
cannula with 4 liters.
-blood pressure
120/80 mmHg
-pulse 80 x/times
-respiratory rate 28
x/times
-temperature 36,7 C
V.
Desi
Name
: Nn. s
No.CM
Age
: 23 years
Date/hours
No
: 0605-2203
Evaluation
Signature
Dx
Saturday
*Subjective (S):
January 10
th
2015
13.00 pm
*Objective (O):
*(A):
The problem is not resolved
*Plan
(P):
Continue intervention
Airway management (3140)
1. monitor respiration and oxygen
2. position the patient to maximaze ventilation
3. teach relation deep breath
4. collaborate in the delivery of oxygen therapy
as needed
Desi