MIDTERM EXAM III

NURSING ENGLISH
NAME : NIKE NI’AMIL
AKMALIA NIM : 1130019076
CLASS : 3B

Assessment Diagnosis Inference Planning Interventions Rationale Evaluation

Subjective : Inefecctive airway Active smoker Code : L.01001 Code : I. 01006 1. Monitor for sputum
- Patients said they clearence After nursing Cough exercises are retention Hari pertama :
were active associated with action for 1x24 effective 2. Identify the ability to S: Patient said it's
smokers since 10 hypersecretion of hours it is Action cough not too tight and
years ago. the airway as Cough with phlegm expected that the Observation 3. Adjust the semi can remove
- The patient has evidenced by ineffective a. Identify ability to fowler or fowler sputum.
difficulty active smoking, airway clearance cough position
expelling sputum excess sputum, will improve 4. Describe the purpose O: Patient looks
b. Monitor the
secretions wheezing, ronchi, Hypersecretion of the with the outcome and procedure for like it can sleep
presence of
patients having airway criteria : effective coughing
difficulty a. Sputum sputum retention 5. Remove secretions in A: The problem is
Objective : Therapeutic
expelling sputum production the sputum container partially resolved
- The patient looks a. Adjust the
pale and coughs secretions, patients from scale 2 6. Instruct a deep breath
said that they were (quite semifowler or in through the nose P: Intervention is
frequently Crowded continued
active smokers increasing) to fowler position for 4 seconds, hold
- The patient
experiences since 10 years ago a scale of 4 b. Remove the for 2 seconds then
shortness of and patients (quite secretions in the remove it from the
breath experienced decreasing) sputum mouth with lips Hari kedua :
- The patient shortness of breath Inefecctive airway b. Breathing Education (rounded) for 8
clearence pattern from a seconds S: Patient said it
sounds a lot of a. Describe the
scale of 2 7. Encourage reducing was more relieved,
secretions purpose and
(quite deep breaths to 3 sleeping was
- Inspection procedure for
increasing) to times already sound
effective asleep
a scale of 4 coughing 8. Encourage a strong
(quite b. Instruct a deep cough immediately O: Patient rarely
decreasing) breath in through after inhaling the 3rd coughs, not pale,
c. Wheezing breath doesn't look tight
the nose for 4
from scale 2
(quite seconds, hold for
A: Problem is
increasing) to 2 seconds then
scale 4 (quite remove it from resolved
decreasing) the mouth with P: Intervention is
lips (rounded) for stopped
8 seconds
c. Encourage
reducing deep
breaths to 3 times
d. Encourage a
strong cough
immediately after
inhaling the 3rd
breath