G.

Nursing Interventions

No Day / Diagnose Objectives / Intervensi Implementasi Evaluasi

date / outcomes

hour
1 12-07- Ineffective Airway After the act of  Assess TTV clients 8.20 12.02

2016 Clearance nursing for 1x24 every 30 minutes  Review TTV clients S:
hour :  Assess the speed,
associated with hours. the patient every 30 minutes - The client says there is
8.20 rhythm, depth and
airway obstruction: demonstrate the results: still congested
difficulty breathing.
excessive mucus. effectiveness of  Assess sura additional TD: 90/60 mmHg O:

airway evidenced by breath P: 40x / I, - The assessment results

 assess breathing
outcomes: N: 98x / i obtained:
patterns
❖ clean breath  Collaboration of S: 36.80C BP: 100/70 mmHg

sounds, no nebulizer therapy  Reviewing rate, P: 28x / I,

 Collaboration of O2
cyanosis and rhythm, depth and N: 92x / i

dyspnea difficulty breathing. S: 36.50C

❖ Indicates that a results: - Client appears uneasy

patent airway (the P: 40x / i - Askultasi breath sounds:

client does not feel  Assessing the sura vesicular

suffocated, additional breath

breathing rhythm, results: A:

respiratory Sura breath wejing the issue is resolved

frequency in the  Reviewing breathing P:

range of normal, patterns Keep itervensi

no abnormal breath results:

sounds) Clients seem

❖ O2 Saturation claustrophobic

within normal  Collaboration of

limits nebulizer therapy

results:
 ventovilin 2.5 ml +

NaCl 3 ml)

 Collaboration of O2

results:

O2 8 L / I with

rebriting mask
 RESUME AND PLANNING THE PATIENT HOME

A. Identity
Name : An. A
RM : 763915
age : 4 yr 7 months
male gender :♂
job :-
religion : Islam
sing RS date : 12-07-2016
Reason Sign RS : An. A Sign hospital with complaints of shortness
B. Drugs are brought home
1. Ambroxsol sirup 15mg 3 x 1
2. Zetrizine sirup 15 mg 3x1
3. Salbutamol 2 mg 2x1
C. Recommendation
1. Consumption of drugs as prescribed
2. Stay away from the factors allergens: dust and cat fur.