Diagnosa Keperawatan :

1. Resiko Cidera2. Gangguan Persepsi Sensori 3. Gangguan Citra Tubuh 4. Gangguan Menelan5. Ketidakefektifan Pola Napas6. Gangguan Pertukaran Gas7. Ketidakefektifan Bersihan Jalan Napas8. Gangguan Komunikasi Verbal 9. Hambatan Mobilitas Fisik

10. Nyeri11. Mual

Prioritas Masalah :

1. Ketidakefektifan Bersihan Jalan Napas2. Ketidakefektifan Pola Napas

NIC NOC Diagnosa Keperawatan

1. Ketidakefektifan Bersihan Jalan NapasNIC :

Activities :

1. Determine the need for oral and/or tracheal suctioning2. Auscultate breath sounds before and after suctioning3. Inform the patient and family abaout suctioning

4. Aspirate the nasopharynx, with a bulb syringe or suction device, as appropriate5. Provide sedation, as appropriate6. Use universal precautions gloves, glogges, and mask , as appropriate7. Insert a nasal airway to facilitate nasotracheal suctioning, as appropriate8. Instruct the patient to take several deep breaths before nasotracheal suctioning and the use supplemental oxygen, as appropriate9. Hyperoxygenate with 100% oxygen, using the ventilator or manual resusitation bag

10. Use sterile disposable equipment for each tracheal suction procedure11. Select a suction catheter that is one half the internal diameter of the endotracheal tube, tracheostomy tube or patients airway 12. Instruct patient to take slow , deep breaths during insertion of the suction catheter via the nasotracheal route13. Leave the patient connected to the ventilator during suctioning. If a closed tracheal suction system or an oxygen insufflation

device adaptor is being used.14. Use the lowest amount of wall suction necessary to remove secretions (e.g. 80 to 100 mmHg for adults)15. Monitor patients oxygens status (SaO2 and SvO2 levels) and hemodynamic status (MAP level and cardiac rhytms) immediately

before, during and after suctioning16. Base the duration of each tracheal suction pass on the incressity to remove secretions and patients respone to suctioning17. Hyperinflate and hyperoxygenate beetwen each tracheal suction pass and after the final suction pass 18. Suction the oropharynx after completion of tracheal suctioning 19. Clean area around tracheal stoma after completion of tracheal suctioning, as appropriate20. Stop tracheal suctioning and provide supplemental oxygen if patient experiences brachycardia in increase in ventricular octops

and/or desaturation21. Vary suctioning techniques, based on the clinical response of the patient22. Note type and amount of secretion obtained23. Send secretion for culture and sensitivity test, as appropriate24. Instruct the patient and/or family how to suction the airway, as appropriate

NOCRespiratory status : Airway Patency (0410)Domain – Physiologic Health ( II)Class – Cardiopulmonary (E)Scale – Extremely compromised to Not compromised (a)Definition : extent to which the tracheo brochial passages remain open

Respiratory status : Airway patency

Extremely compromised

1

Substantially compromised

2

ModeratelyCompromised

3

MildlyCompromised

4

Not compromised

5Indicators

111

1

1

1

1

1

222

2

2

2

2

2

333

3

3

3

3

3

041001041002041003

041004

041005

041006

041007

041008

Fever not presentAnxiety not presentChoking not presentRespiratory rate IERRespiratory rhythm IERMove sputum out of airwayFree of adventitious breath soundsOther ................ (specity)

444

4

4

4

4

4

555

5

5

5

5

5

25. IER : In Expected Range

2. Ketidakefektifan Pola NapasNIC :

Activities :

1. Monitor rate, rhythm, depth, and effort of respirations2. Note chest movement, watching for symmetry use of accesory muscles, and supractivicular and intercostal muscle retractions3. Monitor of noisy respiration, such as crowing or snoring4. Monitor breathing patterns : tachtpnea, hyperventilation, kussmaul respirations, cheyne stokes respirations, apneustic breathing,

biot’s respiration and ataxic patterns5. Palpate for equal lung expansion6. Percuss anterior and posterior thorax from apices to bases bilaterally7. Note location of trachea8. Monitor for diaphragmatic muscle fatigue (paradoxical motion)9. Auscultate breath sounds, nothing areas of decreased/ absent ventilation and presence of adventitious sounds10. Determine the need for suctioning by auscultating for crackles and rhonchi over major airways11. Auscultate lang sounds after treatment to note result12. Monitor PFT values, particularly vital capacity, maximal inspiratory force, forced expiratory volume in 1 second (FEV1), and

FEV1 / FVC, as available13. Monitor mechanical ventilator readings, nothing increase in inspiratory pressures and decrease in tidal volume, as appropriate14. Monitor for increased restlessnes, anxiety, and air hunger15. Note changes in SaO2, SvO2, end-tidal CO2, and ABG values, as appropriate16. Monitor patients ability to cough effectively17. Note onset, charcteristics, and duration of cough18. Monitor patients respiratory secretions19. Monitor for dypsnea and events that decrease and worsen it20. Monitor for hoarseness and voice changes every hour in patient with facial burns21. Monitor for crepitus, as appropriate22. Monitor chest x-ray reports

23. Open the airway, using the chin lift or jaw thurst technique, as appropriate24. Place the patient on sude, as indicated, to prevent aspiration; log roll if cervical aspiration is suspected25. Institute resuscitation efforts, ass needed26. Institute respiratory therapy treatmrnts (e.g. nebulizer), as needed.

NOC

Respiratory Status : Ventilation (0403)

Domain – Physiologic Health ( II)

Class – Cardiopulmonary (E)

Scale – Extremely compromised to Not compromised (a)

Definition : movement of air in and out of the lungs

Respiratory status : Airway patency

Extremely compromised

1

Substantially compromised

2

ModeratelyCompromised

3

MildlyCompromised

4

Not compromised

5Indicators

1

1

1

1

1

222

2

2

2

333

3

3

3

040301

040302

040303

040304

040305

Respiratory rate IERRespiratory rhythm IERDepth of inspiration Chest expansion symmetricalEase of breathing

444

4

4

4

555

5

5

5

040306

040307

040308

040309

040310

040311

040312

040313

040314

040315

040316040317

040318

040319

040320

040321

Move sputum out of airwayVocalizes adequatelyExpulsion of air

Accessory muscle use not presentAdventitious breath sound not presentChest retraction not presentPursed lips breathing not presentDypsnea at rest not present Dypsnea with exertion not presentOrthopnea not presentSOB not presentTactile fremitus not presentPercussed sounds IERAusculated breath sounds IERAusculated vocalization IERBronchophony IER

1

1

1

1

1

1

1

1

1

1

11

1

1

1

1

2

2

2

2

2

2

2

2

2

22

2

2

2

2

3

3

333

3

3

3

3

3

33

3

3

3

3

4

4

444

4

4

4

4

4

44

4

4

4

4

5

5

555

5

5

5

5

5

55

5

5

5

5

040322040323

040324040325

040326

040327

040328

Egophony IERWhispered pectoriloquy IERTidal volume IERVital capacity IER

Chest X-ray findings IERPulmonary function test IER

Other ................ (specity)

11

11

1

1

1

22

22

2

2

2

33

33

3

3

3

44

44

4

4

4

55

55

5

5

5

IER : In Expected Range; SOB : Shortness Of Breath

Daftar pustaka

Johnson, Marion., Maas, Meridean dan Moorhead, Sue. 2000. Nursing Outcomes Classification (NOC). Edition : 2nd. USA : Mosby, Inc

Dochterman, JM. Bulechek, GM. 2004. Nursing Interventions Classification (NIC). Edition : 4th.USA : Mosby. Inc