Nursing Care of

The Respiratory System

Adila Hidayati PO72201201631
Adyt prayoga PO72201201632
Afrillya Sandova PO72201201633
Andre Fitri Santoso PO72201201634
Elis Triana PO72201201639
M. Krisna Ihwandi PO72201201646
Novia Syafitri PO72201201649
Nur Annisa PO72201201651
Suryadi PO72201201662
Tiara Cinta PO72201201663
Windi Putri Suryani PO72201201664
Yusri Angrayni PO72201201665

POLTEKKES KEMENKES TANJUNGPINANG

The respiratory system, is a organs used for gas exchange
processes, where the respiratory system is one of the systems that
play a very important role in the body for support survival. The
respiratory system is made up of several structure, all of these
structures are involved in the process of external respiration,
namely: exchange of oxygen between the atmosphere and blood
and exchange of carbon dioxide between the blood and the
atmosphere, besides that there is also internal respiration, which is
the process of exchange of gases between circulating blood and
tissue cells in which the respiratory system. This internal system
occurs in all body systems.
 a) Nose
The entry of air starts from the nose. The nose is the first organ
in the respiratory system which consists of an external (visible) part and
a part
internals. On the external part of the nose there is a supporting
framework in the form of bones and hyaline cartilage covered by
muscle and skin. Interior structure
of the external part of the nose has three functions:
1) Warming, humidify, and filter incoming air;
2) Detect stimulation olfactory (sense of smell); and
3) Modification of sound vibrations passing through the chamber
great resonance and reverberation. Nasal cavity as an internal
part described as a large space anterior to the skull (inferior to the
nasal bone; superior to the oral cavity); nasal cavity is limited by
muscles and mucous membranes
 b) Pharynx
The pharynx, or throat, is a funnel-shaped tube with a length of 13 cm. The pharyngeal
wall is composed of skeletal muscle and is lined by a membrane mucosa. Relaxed skeletal
muscles keep the pharynx in a fixed position whereas when the skeletal muscles contract,
swallowing is taking place. The function of the pharynx is as a conduit for air and food,
providing resonance chamber for sound during speech, and a place for the tonsils (role in
immune reactions to foreign bodies)
c) Larynx
The larynx is composed of 9 parts of cartilage tissue, 3 single
parts and 3 paired part. The 3 paired parts are the
arytenoid cartilages, cuneiform, and corniculate. The
arytenoid is the most significant part where this tissue
affects the movement of the mucous membrane actual
vowels) to produce sound. The other 3 parts which are The
single parts are the thyroid, epiglottis, and cricoid. Thyroid
and cricoid both serve to protect the vocal cords. Epiglottis
protects the airways and diverting food and drink through
the esophagus
d) Trachea
The trachea or windpipe is a tubular tube through which air
from the larynx to the lungs. The trachea is also lined by
columnar epithelium ciliated so that it can trap substances
other than the incoming air and then climb through the
esophagus to be swallowed or passed through sputum. The
trachea and bronchi also have irritant receptors that stimulate
coughing, forcing large particles that enter back up

e) Bronchi
After the larynx, the trachea divides into two main branches,
the right and left bronchi left, where these branches enter the
right and left lungs as well. Within each lung, the bronchi
continue to branch and narrow, shorter, and the more the
number of branches, such as branches in tree. The smallest
branch is known as the bronchiole (Sherwood, 2010). In COPD
patients, excess mucus is secreted into the bronchial tree so that
causes chronic bronchitis.
f) Lung
The lungs are divided into sections called lobes. There
are three lobe in the right lung and two lobes in the left
lung. Between In both lungs there is a space called the
cardiac notch which is the a place for the heart. Each
lung is covered by two membranes a thin protective
covering called the parietal and visceral pleura.
parietal pleura lines the thoracic wall while the visceral
pleura lines the lungs alone. Between the two pleura
there is a thin layer of lubricating fluid. This liquid
reduce friction between the two pleura so that the two
layers can touch each other while breathing. This fluid
also helps the visceral and parietal pleura adhere to
each other, just as two glass sticks when wet
Assessment is the beginning of the nursing care process and is a systematic process
of collecting data from various data sources to evaluate and identify health
status. This stage includes three activities, namely collecting data, analyzing data,
and determining nursing problems.
Below is the assessment carried out as follows:
a. Data collection
1) Identity
Patient identity.
The patient needs to be assessed: name, age, to determine the provision of
intervention. Religion, to determine the coping used by the client and the client's
beliefs. Ethnicity, to find out whether there are beliefs held by the client during
the healing period. Address, to find out where you live. Medical diagnosis, No.
medical record, date of admission, date of time of assessment.
Patient's family identity
The identity of the person in charge includes: name, age, gender, occupation,
education, and address, relationship with the patient.

2) Medical history
a) Complaints on admission to the hospital
A chronology that describes the behavior of the patient or family in seeking help.
Describes the first time you feel the action taken until the patient comes to the
hospital, the actions that have been obtained until the patient undergoes
treatment.
b) Past medical history
The medical history explains the history of hospitalization, allergies, chronic
diseases, and surgery history. In addition, it also explains about the history of
diseases that are related to the disease the client is currently suffering from, such
as a history of fever, cough, runny nose or a disease similar to the treatment being
carried out.
c) Family medical history
Family medical history explains the condition of the family members whether any
have suffered from a disease similar to the patient in the last 6 months, a history of
infectious diseases, or hereditary diseases.

3) Daily activities
a) Nutritional Pattern
The patient's habits in fulfilling nutrition before illness until the time of illness which
includes: type of food and drink consumed, frequency of food, portion, preferred
food and complaints related to nutrition.
b) Elimination Pattern
Describe the state of elimination of the patient before the illness until the time of
illness which includes: frequency, consistency, color, smell.
c) Sleep Rest Pattern
Filled with the quality and quantity of the patient's sleep from before the illness
until the time of illness, including the number of hours of sleep during the day and
night, the use of bedtimers, or sleep problems.
d) Personal Hygiene Pattern
Filled with how the patient's personal hygiene / personal hygiene, namely asking
the frequency of bathing, brushing teeth, clipping nails, changing clothes from
when he was healthy and when he was sick.
e) Activities
Assess the patient's activity pattern during illness. Usually in patients who are sick
it is difficult to carry out activities according to their development and their
activities decrease because of the impact of physical weakness and more bedrest.

4) Physical Examination
a) General Condition or Appearance
Weakness, mild pain, severe pain, restlessness, fussiness.
b) Level of Awareness
Observation of the patient's level of consciousness, decreased consciousness is often
found ranging from apathy, samnolen, spoor, to coma, assessed using PCS.
c) Vital signs
Examination of vital signs in the form of assessment of respiration, temperature,
pulse.
d) Physical examination
1. Respiratory system
A. Inspection
The following are the inspection methods that must be carried out by nurses
(Irman Somantri, 2007):
a. The patient must be seated and the chest examination should begin from the
posterior chest.
b. Data is observed by contrasting the two sides.
c. From top to bottom, actions are carried out.
d. Inspect the posterior chest for skin color and condition (scars, lesions, and masses)
and spinal disorders (kyphosis, scoliosis, and lordosis)
e. Record the amount. rhythm, depth of breath, and symmetry of chest movement
f. Observation of different breathing techniques, such as hooded breathing,
diaphragmatic breathing, and breathing with accessory muscles
g. Pay attention to the duration of the inspiratory and expiratory phases when
observing breathing. Normal 1:2 ratio
h. Examine chest arrangement and compare AP and lateral diameters. Depending
on the state of the patient's bodily fluids, the ratio might range from 1: 2 to 5: 7.
i. Chest abnormalities including Barrel Chest, Funnel Chest, Pigeon Chest, and
Kyposkoliosis.
j. Examining the symmetry of the chest's movement.
k. Look for aberrant intercostal retraction during inspiration, which could indicate
an airway obstruction.
B. Palpation
Examining the palms, fingers, neck, chest, and belly is the first step in the palpation
process. Lung cancer, lung abscess, emphysema, and bronchiectasis patients all
have clubbed fingers. To determine the pressure in the right atrium, you'll need to
know your jugular venous pressure (JVP). The goal of a neck exam is to see if the
trachea is still in the middle or has migrated to one side, and if lymph nodes have
protruded. The protrusion of the chest wall, pain, symmetrical respiratory
movements, the degree of chest expansion, and the tactile vocal fremitus can all
be determined by palpating the chest. The chest movement is examined by
placing both palms symmetrically on the back, both thumbs beside the vertebral
line, and then asking the patient to take a deep breath. The distance between the
right and left thumbs will be varied if the chest movement is not symmetrical
(Darmanto, 2009).
C. Percussion.
Percussion is used by the nurse to measure pulmonary resonance, surrounding
organs, and diaphragm expansion (excursion). Normal and aberrant
percussion sounds are the two forms of percussion sounds. (Muttaqin Arif.)

D. Auscultation.
Auscultation is a very important evaluation that involves listening to both
normal and abnormal breath sounds. The vibration of air as it moves through
the airway from the larynx to the alveoli produces normal breath sounds.
1. Ineffective airway clearance related to the accumulation of secretions
2. Risk of infection related to invasive measures
3. Anxiety related to hospitalization

a. Clear the airway

Definition: Inability to clear secretions or obstruction from the airways
to maintain a clean airway.
• Characteristic limitations
- No stones - Additional breath sounds
- Changes in breathing pattern - Changes in respiratory rate
- Cyanosis - Verbalization
- Decreased breath sounds - Dyspnea
- Spuntum in excessive amounts - Ineffective cough
- Anxiety - Relevant factors
- Excessive mucus - Be exposed as soon as possible
- Foreign body in the airway - Stopped secretion
- Passive smoker
b. Risk of infection
• Definition: Vulnerable to invasion and multiplication
of pathogenic organisms that can interfere with health.
• Relevant factors • Related conditions
• Peristalsis disorders • Changes in the pH of secretions
• Impaired skin integrity • Chronic disease
• Inadequate vaccination • Decreased ciliary
• Lack of knowledge to avoid exposure to pathogens • Decreased hemoglobin
• Malnutrition • Immunsuppression
• Obesity • Invasive procedures
• shoo • Leukopenia
• Premature rupture of membranes
No Diagnosis Aim Intervention Rational

1. Cleanness Street breath After done Treatment 1. Observe 1. Knowing Changes

Ineffective connecting measures For 3x30 Respiration rate On the body
with buildup ret minutes, Patient could: and heart rate patient
1. Rr deep Normal limit 2. Practice breathing. 2. Helping expenses
(30- 40x/ minute) In a way Blow phlegm
2. H.r. inside. Normal balloon 3. Drink can helping
limit (90- 120x/ 3. Motivation Patient expenses phlegm
minute) many drink 4. Increasing
3. Not found use 4. Education Family knowledge Family
muscles additional for Breathin inside Child care
exercise in 5. Helping Breathing
5. Manage Nebulizer is better
giveaway
2. Risk infection After done Treatment
connecting with measures During times 24,
action infastifs Risk of infection not Going
with Results criteria:
1. Risk of infection Not
happening
2. Not available
improvement Body
temperature
3. Not available Rosy in
Wound area stab
4. Not available swelling in
the area Stab wound
3. Dismay connecting After done action Nursing
with canonization careen 3x24 hours, then
Worried resolved
By criteria Results:
1. Patient not cry
2. Patient willing interact
With people other
1. Observation Wound 1. Knowing Changes On
stab the body patient
2. Monitor TTV 2. Knowing Chance
3. Do dressing infuse infection
4. Educatio family 3. Preventing infection
patient for recognizing 4. Increases An
the sign infection knowledge family
5. Manage quiche and 5. Preventing chance
drugs antibiotics infection
1. Do therapy play on 1. Therapy play can
patient Reduce anxiety patient
2. Monitor rate 2. Knowing rate
defilements and patient anxiety patient
Implementation of family nursing is a process of actualizing the plan
interventions that have been prepared based on the results of data
analysis with take advantage of various sources within the family and
make the family independent in the health sector so as to be able to fulfill
the duties of family nursing.
Clients and families can assess the potential and capabilities of their own
resources and develop it in implementation, namely being able to
recognize problems health of family members, able to make decisions for
problems family health, able to care for sick family members, able to
modifying the environment for family health and being able to use
available health facilities. (Muwarni, 2007).
It is hoped that the patient can perform deep breathing
techniques with good and right. In addition, it is hoped
that the patient does not have shortness of breath again
characterized by a decreased RR, the absence of use
accessory muscles of respiration.
(Regards)
Nurse: "Assalamu'alaikum mother. Assalamu'alaikum ade"
Mother and child: "wa'alaikumsalam"
(Introduction)
Nurse: “Excuse me mom, I'm a nurse Adila Hidayati, just call me a nurse Adila.
Mother, I am the nurse on duty in this room. I work from 07.00 in the morning until
14.00 in the afternoon. Mother if there is anything you can call me in the nurse's room.
Previously, was it true that I was with the mother RESKI of the parents of nindia rosela
whose address is at Jl. Youth No. 38, correct ma'am? ''
Patient's mother: "Yes, mother. Now what do I want to do with my child, nurse?”
Nurse: “I now want to check the condition of the mother's child, nindi . How's mom?"
Patient's mother: "Oh yes, please nurse. But if my child wants it or not, please just ask
the nurse to persuade him, because nindi is a toy, sister.”
Nurse: " Yes, it's okay ma'am."
Sister: “Good morning, de. What are you playing with?"
Nindi: “It's a doll toy again. ”
Sister: "What's that doll called? Can the nurse know?"
Nindi: “this is shaun the sheep doll”
Sister: "The doll is so cute."
Nindi: "Yes sister. Nindi also really likes this doll. Sister has a doll at home?”
Sister: "Sister doesn't have a doll, but sister also likes dolls just like you."
Nindi: "If the sister wants us, we can play dolls with the sisters."
Sister: "Oh, thank you. Sister likes to play with you. But the nurse can't play now."
Nindi: "Why nurse?"
Nurse: "Because now the nurse wants to check on Ade's condition first. Do you want it?"
Nindi: "Are you sick or not, nurse? If you're sick, Nindi doesn't want to.“
Sister: "No dear. The nurse just wanted to check on ade's condition first. But before that, the
nurse wanted to get to know ade first. Sister's name is Umi Nurjanah. Ade can call a nurse,
Sister Umi. What's your name?"
Nindi: “ My name is Nindia Rosella. Sister just call Nindi."
Sister: "Oh yes, nice to meet you, Nindi."
Nindi: "Yes sister."
(Validation Evaluation)
Nurse: "Nindi how are you feeling now?"
Nindi: “Still not feeling well, Sister.”
Nurse: "How did you sleep last night, Nin?"
Nindi: " Nindi couldn't sleep last night, she woke up and the nurse didn't sleep well."
Nurse: "Why does Nindi keep waking up sleeping?"
Nindi: “In this section (pointing to the chest) it hurts and the breath is also short of breath.
Nindi's head hurts too, Nindi keeps coughing, sus"
Nurse: "Yes, then from that the nurse will check on Nindi so that she doesn't have shortness of
breath and her head doesn't hurt anymore."
Nindi: "Yes, Sister Nindi will.“
Aim
Sister: "Dear nurse, now I want to start the examination, okay? By checking Nindi, the nurse
will know about Nindi's illness. That way, the nurse will be able to give the right medicine
and be able to take good care of Nindi. Later, Nindi will follow the instructions that the sister
gave, will you, dear?”
Nindi: "Yes sister."
Nurse: "Now Nindi is lying down, okay?"
Working Phase
(lay the patient on his back and adjust the position that is comfortable for the patient. And start
performing the physical examination procedure which includes inspection, palpation, percussion
and auscultation)
Nurse: "Nindi now take off her clothes, the nurse wants to start the examination."
Nindi: "Yes sister."
Sister: "Do you want to open it with the nurse or do you want to open it with your mother?"
Nindi: "Just open it with Nindi alone, bro."
Sister: "Yes, it's pretentious now, she takes off her clothes and then Nindi lies down.“
(prepare tools and start inspection)
Inspection: (see the shape and movement of the thorax)
Palpation:
Nurse: "Nindi now try to take a breath, okay?"
Nindi: (inhale)
Sister: "Now try Nindi, say seven-seven.
Nindi: "seven-seven."
Percussion: (percussion stage)
Auscultation: (do the auscultation stage)
Termination Phase
(Subjective data)
Sister: "Well, the nurse has finished checking on Nindi. Now how does Nindi feel after being
examined?”
Nindi: “It doesn't hurt anymore, sus (pointing to the chest area). His breath also doesn't sound
and he's not short of breath anymore. But Nindi is still coughing, bro.”
Sister: "Thank God, dear. Sister is happy to hear that. Yes, if you have a cough, the nurse will
give you medicine so that the cough will heal later."
Nindi: "Yes sister. But is it okay, nurse, the medicine?"
Nurse: "If Nindi wants to get better, she has to take medicine, right, dear?"
Nindi: "Yes sister, Nindi wants to go to school again.“
(Objective Data)
After communicating and directly asking the client, the nurse observes the client's condition. The
client looks calm, comfortable, not anxious, his breath returns to normal no longer sounds and
the client seems to be able to rest calmly and comfortably.
( Follow up plan)
Nurse: "Nindi after this examination, this afternoon at 13.00 the nurse is here again to give
medicine."
Patient: "Yes nurse."
(Upcoming Contract)
Nurse: "Nindi tomorrow the nurse will come again to check on Nindi's condition. Now the nurse just
stays because the examination has been completed."

Nindi: "Yes sister."

Sister: “Mother, I have finished doing the examination for today. I live first. Nindi can now rest
again. If there is something you can call me in the nurse's room, ma'am."
Patient's mother: "Yes nurse."
Sister: “Nindi, when you are given medicine, you have to take the medicine. If you are asked to
eat with your mother, you must also want to. Then Nindi can't be so busy playing that she forgets
to take a break. Nindi should get a lot of rest so that she can recover quickly.''
Nindi: "Yes sister. Thank you, sister."
Sister: "Yes, you're welcome dear. Get well soon, Nin. Then don't forget to pray to God to get well
soon, okay?"
Nindi: "Yes sister."
Sister: “My mother lives first, okay? Nindi, the nurse said goodbye first. Assalamu'alaikum mother.
Assalamu'alaikum Nindi."
Mother and patient: “Wa'alaikumsalam. Thank you very much sis."
Sister: "Yes, ma'am. Excuse me mother."
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