Evaluation

Tgl Nursing diagnoses Implementasi Evaluasi

Friday, 24-4- The ineffectiveness of the
2020 airway clearance b / d airway
obstruction is indicated by
1. Monitor respiratory and Friday, April 24, 2020 at
oxygenation status 2:30 p.m.
R /: Respiration: 28x / S: Not reviewed
minute Spo2: 80% O:
2. Position the client to 1. Ku: Decreasing
maximize ventilation Awareness
R /: Semi-fowler client 2. Awareness:
position coma
3. Do suctioning (suction) 3. GCS: E1VtM1
through endotracheal 4. Ventilator
R /: Secret buildup in the Installed
client's airway is reduced 5. RR: 30x / m,
after suction 6. N: 88x /
4. Position to ease M
shortness of breath 7. T: 37, 50C
R /: The client's bed 8. TD: 110 /
position is high (semi 80mmHg
fowler) A: The ineffectiveness of
5. Consult breath sounds, the airway clearance has
note areas where not been resolved
ventilation is decreased or P: Intervention is
absent and additional continued
sounds are present
R /: additional breath
sound stridor

6. Educate the client's

family about the client's
condition.
R /: client's family accepts
whatever happens to the
client because the client is
already critical

7. Collaborate with a team

of doctors in drug
administration
 Ceftriaxone
 Ondansentron
 Ranitidin
 RingerLactate
 Tranexamic Acid
Friday, 24-4- The ineffectiveness of 1. Monitor respiratory Friday, April 24, 2020 at
breathing patterns b / d and oxygenation 2:30 p.m.
2020 neurological disorders are status S: -
characterized by R /: Respiration: O:
 28x / minute Spo2: 1. Ku: Died
80% 2. Awareness: -
2. Position the client to 3. GCS: -
maximize ventilation 4. Mounted
R /: Semi-fowler Ventilator
client position 5. RR: -x / m,
3. Consult breath N: -x / M
sounds, note areas Q: - 0C
where ventilation is TD: - mmhg
decreased or absent A: The ineffectiveness of
and additional breathing patterns has
sounds are present not been resolved
R /: additional breath P: Intervention
sound stridor terminated (client dies)
4. Educate the client's
family about the
client's condition.
R /: client's family
accepts whatever
happens to the client
because the client is
already critical
5. Collaborate with a
team of doctors in
drug administration
 Ceftriaxone
 Ondansentron
 Ranitidin
 RingerLactate
 Tranexamic Acid
Friday, 24-24- Ineffective cerebral tissue 1. Monitor neorological Friday, April 24, 2020 at
2020 perfusion b / d trauma status 2:30 p.m.
Marked by R /: GCS: 2T, E: 1 V: T S: -
M: 1 O:
2. Adjusting the head 1. Ku: Plus
of the bed to 2. Awareness: -
optimize cerebral 3. GCS: -
tissue perfusion 4. Attached
R /: supine client Ventlator,
position 5. RR: -x / m,
3. Provide information N: -x / M
to family / other Q: - 0C
important people 6. TD: -
the client's
circumstances A: The ineffectiveness of
R /: The client's cerebral tissue perfusion
family accepts and has not been resolved
resigns to the client's P: Intervention
increasingly critical terminated (client dies)
situation
4. Collaboration with a
team of doctors in
drug administration
 Ceftriaxone
 Ondansentron
 Ranitidin
 RingerLactate
 Tranexamic Acid