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Student name : Muhammadd Zainuddin

Npm : 2014201310151
Date and time :Tuesday, 18 July 2023
Room :Al-Haitam

Client Name / Age :An. A / 1 Year 11 months

Examination Date :17/07/2023
Medical diagnosis : pneumonia
Assessment Date :18/07/2023

History of Complaints During Assessment:

- Cough
- Have a cold

Focus Data
Subjective data :
- The client's mother says her child is coughing
- Previously, I had been taken to the puskesmas to do a nebulizer, but there was
still no change, the sputum was difficult to come out
Objective Data :
- I : The child looks coughing
The child looks restless
Nose :
- I : there appears to be white mucus
Chest :
- I :symmetrical chest development
- P : no chest wall retraction
- P : deafening lung sounds
- A :The child sounds rhonchi
- TTV
R : 60 x/m
T : 36.5°C
- Anthropometry
TB : 86 cm
BB: 18 kg
LK : - cm
Supporting data
 - There isn't any

Data analysis

NO Data etiology Problem

1 DS Excessive Ineffective airway
- The client's mother says her accumulation of clearance
child is coughing secretions

- Previously, I had been taken

to the puskesmas to do a
nebulizer, but there was still
no change, the sputum was
difficult to come out

DO
- I
The child appears to be
coughing up phlegm
The child looks restless
Nose :
- I :
there appears to be white
mucus
Chest :
- I :
symmetrical chest
development
- P :
no chest wall retraction
- P :
deafening lung sounds
- A:
The child sounds rhonchi
- TTV
R : 60 x/m
T : 36.5°C
- Anthropometry
TB : 86 cm
 BB: 18 kg
LK : - cm

Nursing diagnoses
1. Ineffective airway clearance bd Excessive accumulation of secretions
Nursing Planning
NOC NIC RATIONAL IMPLEMENTATION EVALUATION
After being given 1. Monitor o2 status 1. Knowing the oxygen 1. Reassess respiratory S:
nursing action 1 x 2. Reassess respiratory saturation if there is a function: breath sounds, rate, - The client's mother said that
15 minutes effective function: breath sounds, rate, decrease in O2 in the body rhythm, depth and use of there was still a lot of
airway cleanliness, rhythm, depth and use of 2. Decreased breath sounds are accessory muscles. phlegm and it was difficult
with outcome accessory muscles. an indication of atelectasis, 2. Note the ability to secrete or to expel it
criteria: 3. Instruct the patient's parents crackles are an indication of cough effectively, note the O:
- There are no to adjust the patient's position accumulation of character, the amount of - I :The child appears to be
additional if the patient is tight secretions/inability to clear sputum, the presence of coughing up phlegm
breath 4. Advise and teach the family the airway so that the hemoptysis. The child looks restless
sounds to cough effectively accessory muscles are used - A : The child sounds
- No snoring 5. Perform chest psychotherapy and the work of breathing rhonchi
- Sputum if necessary increases. - TTV
accumulation 6. Note the ability to secrete or 3. To reduce tightness R : 60 x/m
is absent cough effectively, note the 4. To remove secretions A:
- Respiratory character, the amount of 5. To mobilize secretions Ineffective airway clearance has
frequency sputum, the presence of 6. Expulsion is difficult if the not been resolved
within hemoptysis. secretions are thick, the Q:
normal limits 7. Clean secretions from the sputum is bloody due to lung Continue intervention
 mouth and trachea, suction if
necessary.
Collaboration:
8. Administer medications:
mucolytic agents,
bronchodilators,
corticosteroids as indicated
damage or bronchial injuries ( 1, 2 )
that require further
evaluation/intervention
7. Prevent
obstruction/aspiration.
Suction is done if the patient
is unable to secrete
Collaboration
8. Reduces the thickness of
secretions, circle size of the
tracheabronchial lumen,
useful if there is hypoxemia
in a large cavity.