Bersihan Jalan Napas Tidak Efektif D0001

Kategori : Fisiologis

Subkategori : Respirasi

Definisi:

Ketidakmampuan membersihkan sekret atau obstruksi jalan napas untuk mempertahankan

jalan napas tetap paten.

Penyebab

Fisiologis

1. Spasme jalan napas

2. Hipersekresi jalan napas
3. Disfungsi neuromuskuler
4. Benda asing dalam jalan napas
5. Adanya jalan napas buatan
6. Sekresi yang tertahan
7. Hiperplasia dinding jalan napas
8. Proses infeksi
9. Respon alergi
10. Efek agen farmakologis (mis. anastesi)

Situasional

1. Merokok aktif
2. Merokok pasif
3. Terpajan polutan

Gejala dan Tanda Mayor

Subjektif Objektif

(tidak tersedia) 1. Batuk tidak efektif atau tidak mampu

batuk
2. Sputum berlebih/obstruksi di jalan
napas/mekonium di jalan napas
(pada neonatus)
3. Mengi, wheezing, dan/atau ronkhi
kering
Gejala dan Tanda Minor

Subjektif Objektif

1. Dispnea 1. Gelisah
2. Sulit bicara 2. Sianosis
3. Ortopnea 3. Bunyi nafas menurun
4. Frekuensi nafas berubah
5. Pola nafas berubah

Kondisi Klinis Terkait

1. Gullian barre syndrome

2. Sklerosis multiple
3. Myasthenia gravis
4. Prosedur diagnostik (mis. bronkoskopi, transesophageal echocardiography [TEE])
5. Depresi sistem saraf pusat
6. Cedera kepala
7. Stroke
8. Kuadriplegia
9. Sindrom aspirasi mekonium
10. Infeksi saluran napas
11. Asma

Referensi

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evidence-based guide to planning care. 11th Ed. St. Louis: Elsevier.
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the nursing diagnosis ineffective airway clearance. Nursing Diagnoses, 7, 63-69.
Carlson-Catalano. J., Lunney, M.. Paradiso, C., Bruno J., Luise B. K., Martin, T., Massoni, M., 8.
Pachter, S. (1998). Clinical validation of ineffective breathing pattern, ineffective airway
clearance and impaired gas exchange. Journal of Nursing Scholarship, 30. 243-248.
Carpernito-Moyet, L. J. (2013). Nursing diagnosis application to clinical practice. 14m Ed.
Philadelphia: Lippincott Williams & Wilkins.
Newfteld. S. A., Hinz, M. D.. Tiley. D. S.. Sridaromont, K. L., Maramba, P. J. (2012). Cox’s
clinical applications of nursing diagnosis adult, child, women’s, mental health, gerontic,
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Pascoal, L. M., Lopes, M. 0., da Silva, V. M., Beltréo, B. A., Chaves. D. R., Herdman, T. H., 8.
Costa, A. S. (2016). Clinical indicators of ineffective airway clearance in children with
acute respiratory infection. Journal Of Child Health Care: For Professionals Working
with Children in the HospitalAnd Community. 20(3), 324-332.
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V.E.C. de Seosa. M. V. de Oliveira Lopes & V. M. da Silva (2014). Systematic Review and
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