2.

1 WOC

ISPA

Bakteri streptococcus virus

terhirup
hemopylus influenza

Infeksi kuman peradangan Kuman Merangsang

melepas tubuh untuk
Menempel pada endotoksin melepas zat
Menginvasi sel laring pirogen oleh
leokosit
Respon Faring(faringitis)
pertahanan sel Hipotalamus
Aktivasi system Edema kebagian
Penyempit
imun plika termoreguler
↑produksi mukus an jln
napas
Limfadenopati Suhu tubuh ↑
Maserasi vokasoi
mukosa hidung Kongesti hidung regional(tensil)
Suara sesak MK:
Menyumbat hipertermia
Uiserasi membra Kesulitan saat
masuknya
mukosa bernafas

disfagia Perubahan setatus

Rentan infeksi Mk: bersihan
kesehatan anak
sekunder jalan nafas tdk
efektif Menyebar ke
tonsil(tonsilitis) MK : Ansietas b.d
Hospitalisasi
infeksi
Sululitas peritonsilar

Abses peritonsilar
anoreksia
Bakteri masuk
melalui TE ke
Edema pada MK : Ketidak seimbangan nutrisi
telinga
mukosa saluran dari kebutuhan tubuh
Tuba Eustachius
pernafasan atas
sempit intake↓

Mk: Perubahan
Obstruksi
Persepsi/sensori
TE
Inflamasi
TE

Otitis Media
Akut
Drainase telinga
tengah terganggu

1
Infeksi dan akumulasi
sekret di telinga tengah

Sekret dan pus

bertambah

Mk: Gangguan
Kompres Nyeri Gangguan Komunikasi
dingin telinga Pendengaran
Melepaskan Perubahan
Endophrin intensitas nyeri

Memblok transmisi Nyeri: -

serabut saraf sensori Tidak nyeri
A-beta
- Nyer
i
Menurunkan transmisi
nyeri melalui serabut
C dan delta-A Mk: Nyeri
akut
Mk: Isolasi
Gerbang sinaps Sosial
menutup transmisi
nyeri

Menurunakan
Prostaglandin

Menstimulasi
reseptor tidak nyeri

Menghambat
proses inflamasi

2
 BAB III
NURSING CARE

3.1 Case
Mrs. King brings 2,5 years-old Billy to the pediatrician’s office because he has “been
irritable and feverish since last night”. Further history reveals that Billy also had a runny
nose and cough for two days, and that his appetite and fluid intake have decreased since
the fever started. Billy is otherwise healthy, this is the first episodic illness. His physical
examination reveals slight, irritable, 2,5 years-old girl, pulling at ears, temperature of 102
F, nasal congestion with clear discharge, tympanic membranes red and bulging
bilaterally, pharynx slightly red without exudates. Chest clear, abdomen soft without
hepatosplenomegali (HSM) and no meningeal signs.
The Pediatrician diagnoses an upper respiratory infection (URI) and bilateral otitis media
(BOM) and order amoxicillin 250 mg t.d.s for 10 days. You the office nurse, are to
perform the parent teaching for Billy’s home care. During your discussion with Mrs.
King she tells you that she is concerned that Billy is jealous of his new baby sister
because he has occasional tantrums when she holds the baby. She is concerned about
Billy’s development because he recently started to refuse using the potty, a skill that is
newly acquired Mts. King is very attentive to both new baby and Billy throughout the
interview, and she asks you for suggestions in how to help Billy cope to the new arrival.
While doing so, she points out that her husband has been extra attentive to Billy since his
sister was born.

Result of the assessment

A. dentity

Name: An.B Gender: Male

Age: 2.5 years Marital Status: -

Religion: Islam Responsible: Mother Px (BPJS)

Tribe: Java Address: Gresik

Education: Not in School Date MRS: March 15, 2018

Job: - Date Assessment: March 16, 2018

3
 Address: No. Gresik Reg: 2018080007

Dx. Medical: ARI and OMA

B. Health History
1. Main Complaints:
Ms. Px said that her child had a fever

2. Current disease history:

Ms. Px said that her child had a fever and was easily offended. Ms. Px also said that
her child had coughed since two days ago, runny nose (+), weakness (+), swallowing
pain (+), decreased appetite (+). On March 15 2018 the mother took her child to the
emergency room at the IBNU SINA hospital for a check-up, and px health workers
were recommended to take care of their hospital.

3. Past medical history:

Ms. Px said that before Px had a fever at 2 months after DPT, Hb and Polio
immunization.

4. Family disease history:

Ms. Px said that in her family's medical history no one had a contagious and decreased
disease.
5. Immunization History :
BCG : dated 20-11-2016
DPT 1 : dated 10-01-2017
DPT 2 : dated 10-02-2017
DPT 3 : dated 10-03-2017
Polio 1 : dated 20-11-2016
Polio 2 : dated 10-01-2017
Polio 3 : dated 10-02-2017
Polio 4 : dated 10-03-2017
HB 1 : dated 20-10-2016
HB 2 : dated 10-02-2017
HB 3 : dated 10-03-2017
Measles : dated 20-07-2017

4
6. Social History :
a) Parenting:
Ms. Px said that she cared for her own children and was helped by her husband and
parents.
b) Relationships with Family members:
Ms. Px said that the relationship between children and family members is good.
c) Relationships with peers:
Not reviewed
d) Home Environment:
Not reviewed
7. Daily habit patterns :
a) Nutrition
(1) Diet:
Before entering the hospital: px's mother said that her son's Before entering the
hospital drank formula milk and added a portion of baby porridge, usually when
eating with a frequency of 3 times a day, the meal portion was finished.
Hospitalized: px's mother said that during Hospitalized the px appetite decreases
and only drinks formula milk, because of difficulty swallowing.
(2) Sleep rest:
Before entering the hospital: Ms. Px said that the Before entering the hospital had
taken a nap for 3 hours, and slept for 12 hours a night, woke up wanting to drink
milk or wet the bed.
Hospitalized: Ms. Px said that during the Hospitalized her child slept for about 10
hours, due to fuss and crying.
(3) Personal Hygine:
Before entering the hospital: Ms. Px said that Before entering the hospital had
bathed 2 times a day, changed clothes at any time when dirty clothes were
urinated, defecated or sweat and finished bathing.
Hospitalized: Ms. Px said that her son's Hospitalized was not bathed because he
was still having a fever and was only wiped with warm water.
(4) Activities:
Before entering the hospital: Mother said that her child Before entering the
hospital was a cheerful, active child who responded when called.
Hospitalized: Ms. Px said that Hospitalized px moved a little, was weak, cried a
lot, and did not respond when called.

5
 (5) Elimination Pattern:
Before entering the hospital: The mother said that before entering her child's
hospital defecation with a frequency of 2-3x / day with a soft consistency, yellow
urination with a frequency of 5-6x / day solid yellow and distinctive smell.
Hospitalized : Mother said that she entered her children's hospital defecation with
a frequency of 4-5x / day with a soft, brownish yellow consistency. Urination with
a frequency of 6-7x / day, deep yellow and distinctive smell.
.
C. Physical Examination
1. Weak client's general statea.
2. Mentis Compos client awareness
b. Vital sign :
- BP : - - RR : 42×/minute
- P: 110×/minute - Temperature : 38,8 oC
3. weight / height: Before entering the hospital : 13kg/-
Hospitalized : 12kg/ -
4. Head :
a. Hair: black hair color, even distribution of hair, clean scalp, no lumps and
lesions.
b. Eyes: symmetrical eyeball shape, isocorous pupils, anemic conjunctiva, white
spleen not icterus, no tenderness on the palpebral, no visual impairment.
c. The nose: the shape of the nose is symmetrical, the deviation of the septum is
formed, there is clear or runny liquid or mucus, the outer skin of the nose looks red,
the smell function is good.
d. Mouth: pink lips, no stomatitis, gums not swollen / bleeding, mouth does not
smell.
e. Ears: symmetrical ears, clean ear canal, no serum, no hearing aids.
5. Neck : there is no enlargement of the thyroid gland, the throat is red, there is painful
pain.
6. Thorax and Lung : symmetrical (normuches) thorax, no chest wall retraction,
coughing, no intercostae pulls, 42x / minute breathing frequency, vesicular breath
sounds, thoracoabdominal breath type, no respiratory aids
Focused Physical Examination on Assessment of the Respiratory System
1) Inspeksi
 The mucous-pharyngeal membrane looks reddish

6
  Tonsils appear redness and edema
 Looks like an unproductive cough
 There is no scarring and neckThere is no visible use of additional respiratory
muscles, breathing of the nostrils
2) Palpasi
 A fever
 Feel the presence of enlarged lymph nodes in the neck area / tenderness in the
cervical lymph nodes
 Not palpable an enlarged thyroid gland
3) Perkusi
 Normal lung sound (resonance)
4) Auskultasi
 Vesicular breath / no ringing on both sides of the lung.

7. Breasts : -
8. Cardiovascular : pulse frequency 110x / minute, no enlargement of the heart, single
normal heart sound s1 s2, no complaints of chest pain.
9. Abdomen : no protrusion of the umbilicus, no tenderness to the abdomen, no bloating,
no intestinal bisx pmx..
10. Genetalia : -
11. Integumen : white skin, integrity of intact skin, dry skin turgor, no tenderness on the
skin, warm akral.
12. Ekstremitas : no tremors, no muscle aches and also deformities, free movements

D. Flower growth check: Not assessed

E. Investigation Support: Not Assessed
F. Therapy obtained: amoxcilin 250 mg, administration of oxygen (4lt / minute), Infusion
(RL: 7tts / minute)
G. List of Nursing Problems:
1.Clearing the airway is not effective
2. Hypertermia
3. Acute pain
4. Risk of disruption of growth and development

7
G. Data Analysis
DATA ETIOLOGY PROBLEM

DS : Secret registration Clearing the airway is not

-Ms. Px said that her ↓ effective
child had coughed with The airway is blocked
a cold since 2 days ago ↓
Before entering the Difficulty while breathing
hospital
- Ms. Px said that her
child also had difficulty
breathing
DO :
- General condition is
weak
- Anemic conjunctiva
- RR: 42x / minute
- Cough is not effective
- Sputum production (+)
- Cyanosis
- There is a secret in clear
white color

DS : Invasion of Hypertermia
- - Ms. Px said that her Microorganisms
child had a fever since 2 ↓
days from the Before   Hipotamalus gets
entering the hospital thermoregular
- - Ms. Px said that her ↓
child was weak, fussy, Body temperature
and often cried increases
DO:
- General condition is

8
 weak
- Anemic conjunctiva
- Akral is warm Vital sign
:
BP : -
T : 38,8°C
P : 110x/minute
RR : 42x/minute
- Px looks fussy, and
often cries
- Reddish skin
- Swallow pain (+)
- The mucous-pharyngeal
membrane looks reddish
- Tonsils appear redness
and edema
Ds: Inflammatory process Acute pain
- The patient's mother
said that she often saw
her child pulling ears.
- The patient's mother
says the patient is fussy.
Do:
- General condition is
weak
- Vital sign :
BP : -
T : 38,8°C
P : 110x/menit
RR : 42x/menit
- P: The tympanic membrane
is red and bulges
bilaterally
- Q: like in a stab, if you make
sleep the pain is gone
- R: telingah on the right
- S: 3

9
 - T: pain arises suddenly

3.2 Nursing Diagnosis

1. Ineffective airway clearance related to the accumulation of secretions

2. Hypertermia is associated with microorganism invasion

3. Acute pain is related to the inflammatory process

10
11
12
13
14
 BAB IV
PENUTUP

Kesimpulan

Penyakit ISPA adalah salah satu penyakit yang banyak diderita bayi dan anak-anak, penyebab
kematian dari ISPA yang terbanyak karena pneumonia. Klasifikasi penyakit ISPA tergantung
kepada pemeriksaan dan tanda-tanda bahaya yang diperlihatkan penderita, Penatalaksanaan
dan pemberantasan kasus ISPA diperlukan kerjasama semua pihak, yaitu peranserta
masyarakat terutama ibu-ibu, dokter, para medis dam kader kesehatan untuk menunjang
keberhasilan menurunkan angka, kematian dan angka kesakitan sesuai harapan pembangunan
nasional.

15
 DAFTAR PUSTAKA

Achmadi, U.F, 2003.Waspadai Penyakit Menular, Badan Peneliti danPengembangan Depkes

RI, Jakarta. Agustama., 2005.Kajian Infeksi Saluran Pernapasan Akut (ISPA) pada Balita

Buku Ajar Keperawatan Medical Bedah Edisi 8 volume 2. Jakarta : EGC. Mansjoer Arif,
dkk. 2001.
Buku Saku Diagnosis Keperawatan: diagnosis NANDA, intervensi NIC, kriteria hasil NOC
. Jakarta: EGC.
Brooker, Christine. 2001. Kamus Saku Keperawatan Ed.31.EGC : Jakarta.

Brunner and Suddarth’s. 2002. Kapita Selekta Kedokteran. Media Aesculapius FKUI :
Jakarta. Price A, Sylvia, dkk, 2012. Patofisiologi Konsep Klinis dan Proses-Proses Penyakit,
Edisi 6 . EGC: Jakarta. Wilkinson, Judith M. 2011.
DEPKES. 1993. Proses Keperawatan Pada Pasien Dengan Gangguan Sistem Kardiovaskuler.
EGC : Jakarta.

Doenges, E. Marilynn. 1999. Rencana Asuhan Keperawatan Ed. 3.EGC : Jakarta.

Dorland, W. A. Newman. 2002. Kamus Kedokteran. EGC : Jakarta.

http://mantelbangetsatuaskep.blogspot.com/2012/06/askep-ispa.html

http://www.detikhealth.com/read/2009/10/30/143946/1231859/770/miokarditis.

Nasrul Effendi, 1995, Pengantar Proses Keperawatan, EGC, Jakarta.

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