NURSING CARE

ON Nn.T WITH BRONCHITIS

FLAMBOYAN 3 ROOM
GENERAL HOSPITAL SALATIGA

Compiled by:

Name: Desi Ratna Sari

NIM: P13013
Class: 2A

Program Study DIII in Nursing

Institute of Health Science Kusuma Husada Surakarta
2015

I.

PRIORITY NURSING DIAGNOSES

Airway clearance ineffectiveness related to airway obstruction.

II.
No
1

INTERVENTIONS / NURSING PLAN

Objectives and Expected

Interventions
Outcomes
After the act of nursing for *Airway
1x24 hours, airway
Management
clearance ineffectiveness
(3140)
patients can be resolved
1) monitor
and be good with expected
respiration
outcomes:
and oxygen
1. Respiratory status:
status.
Ventilation (0403)
2) Position the
2. Respiratory status:
patient to
Airway patency
maximize
(0401)
ventilation.
effective
3) Teach
cough,
relaxation
breath
deep breath.
sounds
4) Collaborati
clean, no
on in the
cyanosis,
delivery of
able to
oxygen
breathe
theraphy as
easily.
needed.
Good
rhythm of
the breath,
which is not
too fast or
slow,
breathing
frequency
in the good
range is 1624 times
per minute.

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

Medical Diagnosis: bronchitis

No Date/hours Data focus

1
Saturday
*Subjective data:
January 10 Patirnys said
th
2015
shortness of
breath, the body
feels limp.
*objective data:
-Patient appears
shortness of breath
and weakness.
-blood preasure of
120/80 mmHg.
-pulse 80 times
per minute.
-respiratory rate
28 times per
minute.
Temperature of 36,
7C.
-0xygen attached
to the cannula 4
liters.

IV.

: 0605-2203

Problem
Etiology
signature
Airway
airway
Desi
clearance
obstruction.
ineffectiveness

ACTION / IMPLEMENTATION NURSING

Name

: Nn. s

No.CM

Age

: 23 years

Medical Diagnosis: bronchitis

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

2.positioning the patient to

maximize ventilation

*Subjective data:

Desi

Said patient felt

shortness of breath
when lying flat
*objective data:
Patient half-sitting
position

09.45 pm

3.teach relaxation deep

breath

*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.

RECORDS / DEVELOPMENT EVALUATION

Desi

Name

: Nn. s

No.CM

Age

: 23 years

Medical Diagnosis: bronchitis

Date/hours

No

: 0605-2203

Evaluation

Signature

Dx
Saturday

*Subjective (S):

January 10
th
2015

Patients said shortness of breath, nausea,

vomiting

13.00 pm

*Objective (O):

Patient with 4 liters of oxygen

installed , nasal cannula

Irregular breathing patients

Patients with a half-sitting position or

semi fowler

*(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