3.

4 Nursing Action Plan

Name : An.B Dx. Medis : ARI dan OMA

Age : 2,5 year

NO NURSING DIAGNOSES ACTION PLAN RATIONAL

1. Ineffective airway clearance is NIC: Respiratory monitoring :

associated with secretion buildup. Respiratory monitoring : 1. 1. Knowing the level of the disorder that occurs and
Definisi : 1. Monitor rate, rhythm, depth, and helps in determining the intervention that will be
Inability to clear secretions or obstruction effort of respiration given
of the respiratory tract to maintain airway 2. Pay attention to chest movements, 2. Shows the severity of the respiratory disorder that
cleanliness . observe symmetry, use accessory occurs and determines the intervention to be given
NOC : muscles, retract supraclaviculardan 3. Additional breath sounds can be an indicator of
- Respiratory status: Ventilation intercostal muscles airway patency disorders which of course will
- Respiratory status: Airway 3. Monitor additional breath sounds affect the adequacy of air exchange
patency 4. Monitor breath patterns 4. Knowing the airway problems experienced and the
- Aspiracion Control effectiveness of the client's breathing pattern to
Objectives and outcome criteria: After meet the body's oxygen needs
1x24 hours of nursing care, it is expected Airway Management :
that ineffective road cleaning will be Airway management : 5. The presence of the sound of ronchi indicates that
reduced until resolved. 5. Auscultation of additional breath there is excess secretion in the airway
With the results criteria : sounds: Ronchi, wheezing 6. Position maximizes lung expansion and reduce
- Respiratory frequency within 6. Give a comfortable position to breathing efforts. Maximum ventilation opens the
normal limits reduce dipsneu atelectasis area and increases secretion movement
- Normal respiratory rhythms 7. Clean the secret from the mouth and to the large airway that is released
- Normal respiratory depth trachea, do suction as needed 7. Prevent obstruction or aspiration. Sucking can be
- Clients are able to remove sputum 8. Encourage adequate fluid intake needed if the client is unable to issue his own secret
effectively 9. Teach effective coughing 8. Optimize fluid balance and help thin secretions so
- There is no accumulation of that they are easily removed
sputum Airway Suctioning : 9. Chest physiotherapy / back massage can help drop
10. Decide when oral or tracheal secretions in the airway
suctioning is needed 10. Relieve the work of the lungs to fulfill the work of
11. Auscultation of breath sounds before oxygen and meet the oxygen needs in the body
and after suctioning 11. Broncodilators increase the lumen size of the
12. Inform the family about suctioning tracheobronchial branch so that it decreases
actions resistance to air flow
13. Collaboration on the administration Airway suctioning :
of amoxcilin 250 mg 12. The time for proper suction action can help clear
the patient's airway
13. Knowing the existence of additional breath sounds
and the effectiveness of the airway to meet the
patient's O2
14. Provide understanding to the family about the
indications for suctioning
2. Hypertermia is associated with
microorganism invasion.
Definisi :
Increased body temperature above the
normal range.
NOC :
- Thermoregulation
Objectives and outcome criteria: After
1x24 hours of nursing care, it is expected
that the body temperature will decrease
until resolved.
With the results criteria :
- Body temperature within normal
limits
- Pulse and RR are within normal
limits
- There is no change in skin color
NIC : Fever treathment :
Fever treathment : 1. Regular vital sign monitoring can determine the
1. Monitor the ttv as often as possible progress of subsequent nursing
(once every 2 hours) 2. Knowing the amount of fluid lost
2. IWL Monitor 3. To monitor the progress of the disease, child fever
3. Monitor skin color and temperature 4. Knowing the balance between intake and output
4. Monitor intake and output 5. To control respiratory infections, and decrease heat
5. Give anti piretics 6. Giving fluids is very important for patients with
6. Collaboration of intravenous fluids high body temperature
7. Compress clients on folds of thighs 7. By giving compresses, there will be a heat transfer
and axillae process through an intermediary
8. Collaboration on the administration 8. To stop the development of microorganisms .
of amoxcilin 250 mg

3. Acute pain is related to the inflammatory NIC: NIC:

process
Definition:
Unpleasant sensory and emotional
experiences that appear actual or potential
tissue damage or describe damage, sudden
Pain Management
1. Perform a comprehensive pain assessment
including the location of the characteristics of
the duration of the frequency of quality and
precipitation factors
Pain Management
1. As a foundation for carrying out further nursing actions
2. To minimize pain and to provide a comfortable
environment.
3. As an action to reduce pain
attacks or slow intensity from mild to severe 2. Help patients and families to find and find 4. As an action to reduce pain
which can be anticipated with a predictable environmental control support that can affect 5. To prevent additional complications.
end with a duration of less than 6 months. pain such as lighting room temperature and
NOC: noise
- Pain level 3. Select and do pain management
- Pain control 4. Give analgesics to reduce pain
- Comfort level 5. Collaboration if there are complaints and
Aim: pain actions don't work
After 1x24 hours of nursing care, it is expected
that the patient's pain will be reduced to
disappear
Criteria for results:
- The patient's pain decreases to disappear
- The client does not appear to be fussy
- Vital sign is within normal limits