NURSING CARE

INEFFECTIVE AIRWAY CLEARANCE

ARRANGED BY:

RISA HAIRUN NISYAH (2014901080)

POLITEKNIK KESEHATAN KEMENKES TANJUNGKARANG

JURUSAN KEPERAWATAN TANJUNGKARANG

PRODI PROFESI NERS TANJUNGKARANG

TAHUN AKADEMIK 2020/2021

A. Nursing Assessment

1. Patient Identity
a. Name : Tn. A
b. Age : 44 years old
c. Last education : Bachelor of Economy
d. Occupation : Entrepreneur
e. Adress : Sudirman street, number 3B. Central Jakarta.
f. Religion : Islam
g. Status : Married
h. Hospital adm. date : October, 6nd 2020
i. Medical diagnosis : Effusion Pleural
j. Register number : 00.002.504

2. Chief Complaint
Tightness and breathless since two days ago.

3. History of Present Illness

Patient comes to the hospital on October, 6nd 2020 at 10.05 PM with tightness and
breathless since two days. He also feels weak and cant do his activities as well.

4. History of Past Illness

Patient says he often feels tightness after doing his activities, and feels better after
take a rest. He is never hospitalized earlier. Patient says he never had surgery, and
he also has no allergies.

5. History of Family Illness

Patient has hypertension, but he says his family doesn’t have same disease with
him.

6. Physical Examination
Vital signs :
Blood Pressure : 140/120 mmHg
Pulse : 68 x/minutes
Respiratory : 30 x/minutes
Temperature : 37,2o C

7. Head To Toe Physical Examination

a. Head examination
Inpection : ananemis conjunctiva, sclera anikterik, clear lens, pupil isokor,
direct light reflex + / +
Palpation : Has no wound and lumps.

b. Thorax examination
Inspection: chest movement abnormal.
 Palpation: tactile fremitus symmetrical right and left, retraction of the
chest wall (+)
Percussion : Deafening due to accumulation of fluid in the pleural space.
Auscultation: breath sounds ronchi.

c. Heart examination
Inspection: iktus apex invisible
Palpation: iktus cordis palpable at ICS V
Percussion : no enlargement of the heart
Auscultation: heart sounds normal, additional sound (-)

d. Abdomen examination
Inspections: convex abdomen, ascites (-)
Palpation: tenderness (-), rebound (-), the liver was not palpable
Percussion: timpani
Auscultation: bowel sounds normal

e. Integument and extremities examination

Cyanosis (-)
Akral : warm
Skin turgor: normal
Muscle strength : 5/5

f. Genetalys examination
No assessment

g. Neurology examination
Awareness : composmentys
GCS : E=4, M=6, V=5

8. Laboratory Test
Test Value Reference Range
Hemoglobin 12 12-16 g/dL
Erythrocyte Sedimentation Rate (ESR) 43 4-20 mm/L
Glucose 91 ≤ 125 mg/dL
Ureum 28 15-45 mg/dL
Creatinine 0,81 0,7-1,4 mg/dL

9. Therapy Management
Antrain 3x1 amp/iv
Ondan 3x1 mg/iv
Codeine 3x10 mg/iv
Ranitidine 3x1 amp/iv
 B. Data Analysis
No Data Etiology Problem
.
1. Subjective data : Permeability Ineffective airway
- Patient says he felt tightness dan changes fleura. clearance.
breathless since two days ago.
- Patient says his body is weak and
can’t do any activities. Decreased plasma
osmotic pressure.
Objective data :
- Patient seems restless.
- Patient appears pale. Increased systemic
- Obseravation of vital signs : capillary hydrostatic
BP : 140/120 mmHg pressure.
Pulse : 68 x/minutes
Respiratory : 30 x/minutes
Temperature : 37,2o C Reduced dranaise
limfatif

Pulmonary edema
fluid movement and
passing through the
pleural lining
viselaris

Ineffective airway
clearance.

C. Nursing Diagnosis
1. Ineffective airway clearance related to an excessive accumulation of fluid in the
pleural space.
 D. Nursing Interventions For Ineffective Airway clearance

Patient name : Tn. A

Age : 44 years old
Register number : 00.002.504
No. Nursing Nursing Goals Nursing Rationales
Diagnosis Interventions
1. Ineffective After doing the 1. Auscultation of 1. Abnormal
Airway nursing interventions, breath sounds, breath sounds
clearance airway re-effective record their can be heard as
related to an with the criteria : breath sounds, fluid and
excessive 1. Airways as eg; wheezing, mucus
accumulation evidence by krekels, crackles. accumulate.
of fluid in the normal breath 2. Monitor 2. An increase in
pleural space. sounds. respiratory respiratory rate
2. Normal rate and frequency and can be a
depth of vital signs. compensatory
respirations 3. Assess the patient response to
3. Patient will to a comfortable airway
identify and avoid position eg: semi obstruction.
specific factors fowler’s position. 3. Semi fowler’s
that inhibit 4. Perform postural position limits
effective airway drainage. abdominal
clearance. 5. Instruct the contents from
patient to take pushing upward
several deep and inhibiting
breath. lung expansion.
6. Coordinate with 4. clears the
doctor to give airway and
medications as helps prevent
prescribed. respiratory
complications.
5. Take a deep
breath is
recommended
to improve
oxygen
saturation.
6. A variety of
medications are
prepared to
manage
specific
problems.
 E. Nursing Implementations

Patient name : Tn. A

Age : 44 years old
Register number : 00.002.504
No Nursing
Nursing Diagnosis Date/time Signature
. Implementations
1. Ineffective Airway Oct 8th 2020 1. Auscultation of breath Risa
clearance related to an sounds Risa
Risa
excessive 08.20 AM 2. Monitoring Risa
accumulation of fluid respiratory frequency Risa
in the pleural space. and vital signs. Risa
09.00 AM 3. Assessing the patient
to a comfortable
position.
10.15 AM 4. Instructing the patient
to take several deep
breath.
11.25 AM 5. Performing postural
drainage.
12.00 AM 6. Coordinating with
doctor to give
antibiotics and
expectorans.
2. Ineffective Airway Oct 9th 2020 1. Auscultation of breath Risa
clearance related to an sounds Risa
Risa
excessive 10.25 AM 2. Monitoring Risa
accumulation of fluid respiratory frequency Risa
in the pleural space. and vital signs.
Assessing the patient
to a comfortable
position.
11.20 AM 3. Instructing the patient
to take several deep
breath.
11.55 AM 4. Coordinating with
doctor to give
antibiotics and
expectorans.
 F. Progress Notes

Patient name : Tn. A

Age : 44 years old
Register number : 00.002.504
No Nursing
Date Nursing Evaluations Signature
. Diagnosis
1. Ineffective Oct 8th Subjective : Risa
Airway clearance 2020 - Patient says still breathless.
related to an - Patient says often cough.
excessive
accumulation of Objective :
fluid in the - Patient seems weak.
pleural space. - Patient uses respiratory
muscle.
- Observation of vital signs :
BP : 140/110 mmHg
Pulse : 70 x/minutes
Respiratory : 28 x/minutes
Temperature : 36,8o C

Assessment :
Ineffective airway clearance issue
has not resolved

Planning :
Continue nursing
implementations.
1. Auscultation of breath
sounds.
2. Monitoring respiratory
frequency and vital signs.
3. Instructing the patient to take
several deep breath.
4. Coordinating with doctor to
give antibiotics and
expectorans.
2. Ineffective Oct 9th Subjective : Risa
Airway clearance 2020 - Patient says it feels better than
related to an his previous condition.
excessive - Patient says can do light
accumulation of activities by himself.
fluid in the
pleural space. Objective :
- Patient seems breathe well.
- Patient seems relax.
- Observation of vital signs :
BP : 120/70 mmHg
Pulse : 70 x/minutes
 Respiratory : 24 x/minutes
Temperature : 36,5o C.

Assessment :
ineffective airway clearance issue
has resolved

Planning :
Stop nursing implementations.