NAMA : IRMA ZULHAFNI TRIANTARI

NIM : P07120421027N

KELAS : A

B. NURSING DIAGNOSES
1. Ineffective airway clearance related to accumulation of secretions
2. Ineffective breathing pattern associated with a decreased ability to breathe

C. INTERVENTION
a. Ineffective airway clearance related to accumulation of secretions.
Objective: airway re-effective
Expected outcomes:

 can demonstrate effective cough

 can declare a strategy to reduce the viscosity of secretions

Intervention

1. Auscultation of breath sounds, record their breath sounds, eg; wheezing, krekels,
crackles.
R: some degree of bronchospasm occurs obstruction in the airway

2. Assess / monitor respiratory frequency.

R: tachypnea normally exist in some degree and can be found at the reception or during
stress

3. Assess the patient to a comfortable position eg: raising the head of the bed, sitting on
the back of   the bed.
R: clod elevation makes it easier to breathe

4. Push / aids abdominal breathing exercises / lip

R: give patients a way to remedy and resolve dyspnea memgontrol

5. Observation of cough characteristics eg settling, hacking cough, wet

R; short cough, moist secretions usually come out with a cough
 6. Perform suctioning
R: to lift off the road respiratory ssekret

7. Koaborasi with doter

R: for drug delivery

b. Ineffective breathing pattern b / d decreased ability to breathe.

Objective: patient breathing pattern becomes effective

Expected outcomes:

 Chest no disturbance development

 Breathing becomes normal 18-24 x / min

       Intervention

1. Monitor frequency, rhythm and depth of breathing

R: dyspnea and an increase in employment of breath, respiratory depth varies
throughout

2. Elevate the head and help reposition

R: high dududk enables lung expansion and ease breathing

3. Observe the pattern of coughing and secretions character

R: know the dry cough or wet cough as well as the color of the secretions

4. Give the patient practice deep breathing or coughing effective

R: may increase secretions in which there is an interruption in breathing inconveniences
ventilation sitambah

5. Provide additional O2
R: maximize breathing and lower the breath work

6. Auxiliary chest physiotherapy

R: facilitate efforts to breathe preformance and increase secretions draenase

D. IMPLEMENTATION

a. Ineffective airway clearance related to accumulation of secretions.

 1. Auscultation of breath sounds, record their breath sounds, eg; wheezing, krekels,
crackles.
Result : ronkhi sound

2. Assess / monitor respiratory frequency.

Result : RR = 30x/m

3. Assess the patient to a comfortable position eg: raising the head of the bed, sitting on
the back of   the bed.
Result: patient comfortable with semi fowler positionon

4. Observation of cough characteristics eg settling, hacking cough, wet

Result: phlegm cough

5. Perform suctioning
Result: The patient appears more relieved to have suction performed.

6. Coaboration with docter in drug administration

Result: Patients are given a nebulizer.

b. Ineffective breathing pattern b / d decreased ability to breathe.

1. Monitor frequency, rhythm and depth of breathing

R: RR= 30x/m

2. Elevate the head and help reposition

R: The patient feels more comfortable.

3. Observe the pattern of coughing and secretions character

R: characteristics of phlegm cough

4. Give the patient practice deep breathing or coughing effective

R: Patients are able to perform effective coughs independently

5. Provide additional O2
R: patient feels more comfortable and the tightness is slightly reduced
E. EVALUATION

a. Ineffective airway clearance related to accumulation of secretions.

 Subjective : The patient said he was still coughing with phlegm.

 Objective :
Patient looks short of breath
There is a secret
There ronki
TTV :
BP: 120/80 mmHg
P: 80x/m
RR: 27x/m
T: 36oC
 Asessement : the problem has not been resolved
 Planning : Continued intervention

b. Ineffective breathing pattern b / d decreased ability to breathe

 Subjective : patient says still tight

 Objective :
Patient looks short of breath
Patient looks pale
TTV :
BP: 120/80 mmHg
P: 80x/m
RR: 27x/m
T: 36oC
 Asessement : the problem has not been resolved
 Planning : Continued intervention