members of the group

1. SITI NUR KHOLIFATUS SAMSIYAH 1923031)01035)

2. IKE NELI AGUSTIN (192303101036)
3. SHOFIA LAILATUL MUKAROMAH (192303101108)
4. CITRA PUJANGGA (192303101186)

Problem : Data A 68-year-old man was admitted to the hospital for severe shortness of breath
and inability to care for himself at home. He was diagnosed with chronic obstructive pulmonary,
He complains of being severely fatigued and short of breath

Diagnosis Patient Goals and Nursing Evaluation

Expected Interventions
Outcomes
ineffective airway After being given 1. Monitor subjective data
3x4 hours of respiratory and
clearance
nursing care, it is oxygenation status 1. the patient said he
DS : hoped that the 2. Alkulturation was not short of
patient's complaints every 2 to 4 hours breath.
1. The patient says
can be resolved 3. Monitor for 2. objective data
his breathing has
with the following hypoxia 3. drop
become worse
criteria: 4. Assess respiratory RR from 36x /
since the weather
1. Respiration rate distress data: minute to 20x /
is cold with a rain
returns to increased HR, minute,
fan
normal irritation, sweating 4. decreased chest
2. The patient
2. Respiratory a lot retraction,
pronounces
rhythm is 5. Keep rest between 5. And no exhalation
shortness of
resolved activities muscle use, no
breath
3. Depth of 6. Position the semi- cyanosis, CRT <2
DO:
inspiration is fowler patient seconds, akral
1. The patient
overcome 7. Teach instructions warm.
appears tired and
4. Airway for effective The results of the
short of breath
compliance coughing and deep assessment of breathing
2. Patient looks
returns to breathing pattern problems are not
emaciated and
normal 8. Collaborate with effectively resolved and
sweaty, and
physicians in for Intervention planning
lordosis
administering 5% is stopped with discharge
3. Temperature:
dextrose drug and planning. Instruct the
100.8 ° F orally
initiating patient to identify
N: 104 x / minute
aminophylline activities that are
RR: 36x / minute
dripping involvedcauses shortness
TD: 146/92 mm
of breath and reduce it,
Hg
instruct the patient to
4. The patient is
 wheezing and routine control after
crackling all over returning home sick as
the body well as on the monitor for
fluid intake and output.
gas exchange After being given 1. Position the DS:
interruption nursing care for 3x4 patient to 1. 1. The patient
DS: hours, it is hoped maximize does not appear to
patients complain of that the patient's ventilation have difficulty in
cold weather complaints can be 2. Position to lighten breathing. 2.
resulting in worse resolved by the the breath 2. the patient is back
breathing and following: 3. Monitor oxygen in shape or not
complain of 1. Oxygen flow tired. TO DO:
shortness of breath saturation within 4. Teach the use of 3. respiratory rate
and fatigue normal ranges oxygen which 20 breaths /
DO: 2. No dyspnea at facilitates mobility minute
respiratory rate 36 rest 5. Monitor speed,
breaths / minute 3. Respiratory rate rhythm, depth and
within normal difficulty
ranges breathing
4. Regular 6. Monitor additional
breathing rhythm breath sounds
5. There is no use such as grunting
of the auxiliary or wheezing
muscles 7. Monitor breathing
6. No additional patterns
sound
activity intolerance After being given 1. Identify deficits in DS: the patient said he
DS: very tired nursing care for activity levels was not tired.
because of breath 3xe4 hours, it is 2. Identify the ability DO:
DO: hoped that the to participate in the patient does
blood pressure, patient's complaints certain activities not use the
146/92 mm Hg can be resolved by 3. Monitor auxiliary muscle
respiratory rate, 36 the following: emotional, muscles. the
breaths / minute 1. Complaints of physical, social, patient is easier to
heart rate, 104 beats / fatigue and spiritual breathe.
minute decreased responses to blood pressure,
2. Pulse rate activities 120 / 80mm Hg
increases (60- 4. Facilitate motor respiratory rate:
100x / minute) activities to relax 20 breaths /
3. Feelings of muscles minute
weakness 5. Teach how to do heart rate, 100 beats /
decreased the selected minute
4. Blood pressure activity
improves 6. Encourage family
(systole: 100- to provide
140 mmHg, positive
 diastole: 60-90 reinforcement for
mmHg) participation in
5. Oxygen activities
saturation
increases
6. The ease of
doing daily
activities
increases
7. Breath rate
improves (16-
22x / minute)