Data

DS:
- Tn. Cungkring
merasa susah
napas/ abnormal
breathing
- sakit kepala/
headache
- diaforesis/
diaphoresis
DO:
-

Data

Etiologi
Perubahan membrane
alveolar kapiler b.d
gangguan pertukaran gas
(Alveolar apillary
membrane changes r.w
impaired gas exchange)

Masalah keperawatan
Impiared Gas Exchange
(00030)
Domain : 3 Elimination
and Exchange
Class : 4 Respiratory
function
Axis
Axis
Axis
Axis
Axis
Axis
Axis

Pernapasan cuping
hidung/ Nasal
flaring
pernapasan
abnormal /
abnormal breathing
rate 27x/menit
BTA (basil tahan
asam) (+)
- penurunan carbon
dioksida/ decreased
carbon dioxide
PCO2 49mmHg
Etiologi

I : pertukaran gas
II : Individu
III: impaired
IV: kardiopulmonal
V : dewasa
VI : akut
VII : actual

Maslah keperawatan

DS:
-

DO :
-

Tn. Cungkring
merasa susah
napas

Pernapasan cuping
hidung
Perubahan
frekuensi napas
(27x/menit)
Batuk tidak efektif
/ineffective cough
Sputum dalam
jumlah yang
berlebih / Excessive
sputum (lender
kental , kuning
kehijauan ,
terkadang disertai
bercak darah)

Data
DS:
- Tn. Cungkring
merasa susah
napas
- Fatique
- Malaise
- Diaphoresis
DO:
-

Data

Environmental : Smoking
Obstructed Airway :
foreign body in airway
Physiological : Chronic
obstructive pulmonary
(penyakit paru obstruksi
kronis b.d ketidak
efektifan bersihan jalan
nafas / ineffective airway
clearance)

Ineffective airway
clearance
(00031)
Domain : 11 safety /
protection
Class : 2 physical injury

Etiologi
Keletihan otot pernapasan
/ respiratory muscle
fatique
b.d ineffective breathing
pattern

Masalah keperawatan
Ineffective breathing
pattern
(00032)
Domain : 4 Activity / rest
Class : 4 cardiovascular /
pulmonary responses

Axis
Axis
Axis
Axis
Axis
Axis
Axis

Axis
Axis
Axis
Axis
Axis
Axis
Axis

Pernapasan cuping
hidung / nasal
flaring
Penggunaan otot
aksesoris / use of
accessory muscles
to breathe

Etiologi

I : perttukaran gas
II : Individu
III: ineffective
IV: kardiopulmonal
V : dewasa
VI : akut
VII : actual

I : perttukaran gas
II : Individu
III: ineffective
IV: kardiopulmonal
V : dewasa
VI : akut
VII : actual

Masalah keperawatan

DO:
-

No .
priorit
as
1

Body weigh 20% or

more below ideal
weight range
(berat badan 20%
atau lebih di bawah
berat badan ideal)
Lack of food
(kurang makan)
Rumah Tn,
Cungkring 5x6
meter ,ventilasi
hanya berasal dari
satu pintu
,lingkungan lembab,
lantai dari tananh,
atab terbuat dari
asbes, dan kegiatan
memasak dilakukan
di ruangan tersebut
dengan peralatan
minimal.

Insufficient finances r.w

imbalanced nutrition less
than body requirements
(ketidak seimbangan
nutrisi kurang dari
kebutuhan tubuh b.d
factor ekonomi

Imbalanced nutrition less

than body requirements
(00002)
Domain : 2 Nutrition
Class: 1 ingestion
Axis
Axis
Axis
Axis
Axis
Axis
Axis

I : nutrition
II : Individu
III: imbalanced
IV: gastrointestinal
V : dewasa
VI : akut
VII : actual

Kode
diagnose

Diagnose keperawatan

Tanggal
muncul

00030

Impaired gas exchange , individu,

pulmonary, dewasa ,akut, actual, b.d
perubahan memebran alveolar
ditandai dengan pasien merasa
susah nafas, sakit kepala
,diaphoresis, pernafasan cuping
hidung,RR=27x/menit , BTA (+) ,

01/10/201
2

Tanggal
teratasi

penurunan pCO2 =49 mmHg

00031

00032

00002

Ineffective airway clearance ,

individu, pulmonary ,dewasa, akut,
actual, b.d (merokok, materi asing
dalam jalan nafas, penyakit paru
obstruksi kronis ) ditandai dengan
dengan pasien merasa susah napas
(RR=27x/menit) ,pernapasan cuping
hidung, batuk tidak efektif, sputum
dalam jumlah berlebih(lender kental,
kuning kehijauan,terkadang disertai
bercak darah)
Ineffective brething pattern ,
individu, pulmonary,
dewasa,akut,actual b.d keletihan
otot pernapasan ditandai dengan
pasien merasa susah napas
(RR=27x/menit),fatique ,malaise,
diaphoresis,pernapasan cuping
hidung, penggunaan otot aksesories
untuk bernapas
Imbalanced nutrition less than body
requirements ,individu
,gastrointestinal , dewasa, akut,
actual b.d factor ekonomi ditandai
dengan berat badan 20% atau lebih
di bawah berat badan ideal ,kurang
makan , Rumah Tn, Cungkring 5x6
meter ,ventilasi hanya berasal dari
satu pintu ,lingkungan lembab,
lantai dari tananh, atab terbuat dari
asbes, dan kegiatan memasak
dilakukan di ruangan tersebut
dengan peralatan minimal.

NOC

Taxonomy of Nursing outcome

Level 1
Domain
Level 2
Classes
Level 3
outcom
es

No .
prioritas

(2) domain II .-Physiologic Health

Outcomes that describe organic functioning
E- Cardiopulmonary
Outcomes that describe an individuals cardiac,pulmonary,
circulatory, or tissue perfusion status
0415
Respiratory status
0402
Respiratory status : gas exchange
0403
Respiratory status : ventilation
0408
Tissue perfusion : pulmonary

Kode
diagnose

NOC (Nusrsing outcome classification )

00030

Gas Exchange : impaired / gangguan pertukaran gas

Definition : excess of deficit in oxygenation and / or carbon dioxide
elimination at the alveolar capillary membrane .
(kelebihan dan kekurangan atau eliminasi karbondiosida di membrane
capilar-alveolar.)
Suggested outcomes:
Acute confution level
Respiratory status
Respiratory status : gas exchange
Respiratory status : ventilation
Tissue perfution : pulmonary
Vital signs
Outcome target ranting :
Respiratory status ----0415
INDICATOR:

041501
041502
041509
041510
041518
041528
041531

Serve
1

Substantia
l
2

Moderate
3

Mild

Substantia
l
2

Moderate
3

Mild

Respiratory rate
Respiratory rhythm
Oxygen saturation
Accessory muscle use
Diaphoresis
Nasal flaring
Coughing

Respiratory status : Gas Exchange ----0402

INDICATOR:

040208

040209

040213

Serve
1
Partial pressure of
oxygen in arterial
blood (PaO2)
Partial pressure of
carbon dioxide in
arterial blood (PaCO2)
Chest x-ray findings

Respiratory status : ventilation ----0403

INDICATOR:

040311
040331

Serve
1

Substantia
l
2

Moderate
3

Mild

Serve
1

Substantia
l
2

Moderate
3

Mild

Chest retraction
Accumulation of
sputum

Tissue perfusion : pulmonary ----0408

INDICATOR:

040820
040805
040824

Arterial PH
Chest pain
Impaired gas
exchange

NIC
Taxonomy of Nursing Interfentations,
Level 1
Domain
Level 2
Classes

Level 3
Interventio
ns

Level 1
Domain

Level 2
Classes

Level 3
Interventio
ns

2.
Physiological : comlex-contd
Care that support homeostatic regulation
K.
Respiratory manajement
Interventions to promote airway patency and
gas exchange
3140
Airway manajement
3250
Cough enhancement
3160
3Airway suctioning
3230
Chest physiotherapy
3320
Oxygen therapy
3350
Respiratory monitoring
8880
Environmental risk protection

7
Community
Care that supports the health of the
community
C.
Community risk management : interfention that
assist in detecting or preventing health , risks
to the whole community
8880
Environmental risk protection

The Classification,
Domain

Classes

Interventions

2
Physiological : comlexcontd
Care that support
homeostatic regulation

K
Respiratory
manajement
Interventions to
promote airway
patency and gas
exchange

3140
Airway manajement
Definition : facilitation of patency of air
passage

Activities:

Open the airway, using the chin lift or jaw thrust technique, as appropriate
Position patient to maximize ventilation potential
Identify patient requiring actual/potential airway insertion
Insert oral or nasopharyngeal airway, as apporopriate
Perform chest physical therapy, as appropriate
Remove secretion by encouraging coughing or sactioning
Encourageslow,deep breathing; turning; and coughing
Use fun techniques to encourage deep breathing for children (e,g., blow
bubbles with bubble blower; blow on pinwheel, whistle, harmonica, balloons,
party blowers; have contest using ping-pong balls,feathers)
Instruct how to cough effectively
Assist with incentive spirometer, as appropriate
Auscultate breath sounds, noting areas of descreased or absent ventilation
and presence of adventitious sounds
Perform endotraceal or nasotracheal suctioning, as appropriate
Administer brocodilators, as approoriate
Teach patient how to use prescribed inhalers, as appropriate
Administer aerosol treatments, as appropriate
Administer ultrasonic nebulizer treatment, as appropriate
Administer humidified air or oxygen, as appropriate
Remove foreign bodies with Mcgill forceps, as appropriate
Regulate fluid intake to optimize fluid balance
Position to alleviate dyspnea
Monitor respiratory and oxygenation status, as appropriate

1st edition 1992; revised 3rd edition 2000; revised 4th edition 2004
Backround Readings:
American Association of critical-Care Nurses. (1998). Core curriculum for
critical care nursing (5th ed.). St. Louis. MO: Mosby.

Racht, E. M. (2002). 10 pitfalls in airway management: How to avoid

common airway management complications.
Jems: journal of emergency Mrdical Services,27(3), 28-34, 36-38, 40-42.

Domain

Classes

Interventions

2
Physiological : comlexcontd
Care that support
homeostatic regulation

K
Respiratory
manajement
Interventions to
promote airway
patency and gas
exchange

3250
Cough enhancement
Definition: promotion of deep inhalation
by the patient with subsequent
generation of high intratoracic
pressures and compression of
underlying dung parenching for the
forceftil expulsion of air.

Activities:

Monitor results of pulmonary function tests, particulary vital capacity,

maximal inspiratory force, forced expiratory volume in 1 second (FEV1), and
FEV1/FVC, as appropriate
Assist patient to a sitting position with head slightly flexed, shoulders relaxed,
and knees flexed
Encourage patient to take several deep breaths
Encourage patient to take a deep breath, hold it for 2 seconds, and cough two
or three times in succession
Instruct patient to inhale deeply, bend forward slightly, and perform three or
four huffs (against an open glottis)
Instruct patient to inhale deeply several times, to exhale slowly, and to cough
at the end of exhalation
Initiate lateral chest wall rib spring techniques during the expiration phase of
the cough maneuver, as appropriate
Compress abdomen below the xiphoid with the flat hand, while assisting the
patient to flex forward as the patient coughs
Instruct patient to follow coughing with several maximal inhalation breaths
Encourage use of incentive spirometry, as appropriate
Promote systemic fluid hydration, as appropriate
Assist patient to use a pillow or rolled blanket as a splint against incision
when couhing

1st edition 1992; revised 4th edition 2004

Background readings;
Perry, A. G., & Potter, P. A. (2002). Clinical nursing skills and technique
(5th ed.). St. Louis, MO: Mosby.

Thelan, L. A., & Urden, L. D. (1993). Critical care nursing: Diagnosis and
management (2nd ed.). St. Louis, MO: Mosby

Domain

Classes

Interventions

2
Physiological : comlexcontd
Care that support
homeostatic regulation

K
Respiratory
manajement
Interventions to
promote airway
patency and gas
exchange

3160
Airway suctioning
Definition: removal of airway secretion
by inserting a suction catheter into the
patiens oral into infron of trachea.

Acthivities :

Determine the need for oral and or tracheal suctioning

Auscultate breath sounds before and after suchtioning
Inform the patient and family about suchtioning
Aspirate the nasopharynx with a buld syringe or suction device,as
appropriate
Provide sedation, as appropriate
Use universal precaution : gloves,goggles,and mask, as appropriate
Insert a nasal airway to facilitate nasotracheal suchtioning,as approphriate
Instruct the patient to take several deep breaths before nasotracheal
suctioning and use supplemental oxy-gen as appropriate
Hyperoksigenate with 100% axygen, using the ventilator or manual
resuctitation bag
Hyperinflate at 1 to 1,5 times the preset tidal volume using the mechanical
ventilator, as appropriate
Use sterile disposable equitment for each tracheal suction procedure
Select a saction catheter that is one half the internal diameter of the
endotracheal tube, traceostomy tube, of patients airway
Instruct the patient to take slow, deep breaths during insertion of the suction
catheter via the nasotracheal route
Leave the patient connected to the ventilator during sactioning, if a closed
tracheal saction system or an oxy-gen insufflation device adaptor is being
used
Use the lowest amount of wall saction necessary to remove secretions (e.g.,
80 to 100 mmHg for adults)
Monitor patients oxygen status (SaO2 and SvO2 levels) and hemodynamic
status (MAP level and cardiac rhythms) immediately before, during, and after
sactioning
Base the duration of each tracheal suction pass on the necessity to remove
secretions and the patients response to sactioning

Hyperinflate and hyperoxygenate between each tracheal suction pass and

after the final suction pass
Suction the orapharynx after completion of tracheal suctioning
Clean area around tracheal stoma after completion of tracheal sactioning, as
appropriate
Stop tracheal suctioning and provide supplemental oxygen if patient
experiences bradycardia, an increase in ventricular ectopy, and/or
desaturation
Vary suctioning techniques, based on the clinical response of the patient
Note type and amount of secretions obtained
Send secretions for culture and sensitivity tests, as appropriate
Instruct the patient and/or family how to suction the airway, as appropriate

1st edition 1992

Background readings:
Barnes,C., & Kirchhoff, K. T. (1986). Minimizinghypoxemia due to
endotracheal suctioning: A review of the literar\ture.
Heart & Lung, 15(2),164-176.
Craven, R. F., & Hirnle, C.J. (2000). Fundamentals of nursing: Human
health and function. (3rd ed.). (pp. 825-827). Philadelphia:
Lippincott Williams & Wilkins.

Domain

Classes

Interventions

2
Physiological : comlexcontd
Care that support
homeostatic regulation

K
Respiratory
manajement
Interventions to
promote airway
patency and gas
exchange

3230
Chest physiotherapy
Definition : assisting the patient to
move airway secretions from
peripheral air way to more central
airways for expectoration /or
suctioning

Activities:
Determine presence of contraindications for use of chest physical therapy
Determine which lung segment(s) to be drained in uppermost position
Use pillows to support patient in designated position
Use percussion with postural drainage by cupping hands and clapping the
chest wall in rapid succession to produce a series of hollow sounds
Use chest vibration in combination with postural drainage , as appropriate
Use ultrasonic nebulizer , as appropriate
Use aerosol theraphy, as appropriate
Administer bronchodilarors , as appropriate
Monitor amount and type of sputum expectoration
Encourage coughing during and after postural drainage
Monitoring patient tolerance via SaO2, respiratory rhythm and rate ,cardiac
rhytm and rate, and comfort levels

1st edition 1992

Background radings:
Brooks-Brunn, J.(1986). Respiration. In L. abels (Ed.), Critical care nursing:
A physiologic approach (pp.168-253). St. Louis, MO: Mosby.
Craven, R F., & Himle , C.J. (2000). Fundamental of Nursing: human health
fungtion (3rd ed,). (pp. 810-813). Philadelphia: Lippincott Williams &
Wilkins.
Kiriloff, L. H., Owens, G. R., Rogers, R. M. & Mazzocco, M. C. (1985). Does
chest physical therapy work? Chest, 88(3), 436-444
Nelson, D M. (1992). Intervention related to respiratory care . in G. M
Bulechek & J.C McCloskey (Eds.), Symposium on nursing interventions:
Nursing Clinics of North America , 27(2), 301-324
Smeltzer, S.C .,& Bare, B. G. (2004). Brunner&Suddarths textbook of
medical surgical nursing, (Vol. 2.) (10th ed,). Philadelphia: Lippincott
Williams & Wilkins.
Sutton, P., Parker, R., Webber, B., Newman, S., Garland , N., LapezVindriera, M., D & Clark, S. W (1983). Assesment of the forced expiration
thecnique, postural drainage, and diregted coughing in chest
physiotherapy. European Jurnal of Respiratory Disease, 64(1)62-68.
Domain

Classes

2
Physiological : comlexcontd
Care that support
homeostatic regulation

K
Respiratory
manajement
Interventions to
promote airway
patency and gas
exchange

Interventions
3320
Oxygen therapy
Definition : administration of oxygen
and monitoring of its effectiveness

Activities:

Clear oral, nasal, and tracheal secretions, as appropriate

Restrict smoking
Maintain airway patency
Set up oxygen equipment and administer through a heated, humidified
system
Administer supplemental oxygen as ordered
Monitor the oxygen liter flow
Monitor position of oxygen delivery device
Instruct patient about importance of leaving oxygen delivery device on
Periodically check oxygen delivery device to ensure that the prescribed
concentration is being delivered
Monitor the effectiveness of oxygen therapy (e.g., pulse oximetry, ABGs), as
appropriate
Assure replacement of oxygen mask/cannula whenever the device is removed
Monitor patients ability to tolerate removal of oxygen while eating

Change oxygen delivery device from mask to nasal prongs during meals, as
tolerated
Observe for signs of oxygen-induced hypoventilation
Monitor for signs of oxygen toxicity and absorption atelectasis
Monitor oxygen equipment to ensure that it is not interfering with the
patients attempts to breathe
Monitor patients anxiety related to need for oxygen therapy
Monitor for skin breakdown from friction of oxygen device
Provide for oxygen when patient is transported
Instruct patient to obtain a supplementary oxygen prescription before air
travel or trips to high altitude, as appropriate
Consult with other health care personnel regarding use of supplemental
oxygen during activity and/or sleep
Instruct patient and family about use of oxygen at home
Arrange for use of oxygen devices that facilitate mobility and teach patient
accordingly
Convert to alternate oxygen delivery device to promote comfort, as
appropriate

1st edition 1992; revised 3rd edition 2000

Background readings:
American association of critical care nurses. (2006). Care curriculum for
critical care nursing (6th ed.) [J. G. Alspach, Ed]. Philadelphia: W. B.
Saunders.
Gottlie, B. J. (1998). Breathing ang gas exchange. In M. Kinney, D. Packa,
& S. Dunbar (Eds.), AACNs clinical reference for critical-care nursing (2nd
ed.) (pp. 160-192). St. Louis, MO:Mosby.
Lewis, S. M., & Collies, I. C. (1996). Medical-surgical nursing: assement
and management of clinical problems (4th ed.) St. Louis, MO: Mosby
Nelson, D. M. (1992). Interventions related to respiratory care. In G. M.
Bulechek & J. C. McCloskey (Eds.), symposium on nursing interventions.
Nursing clinics of north america, 27(2), 301-323
Suddarth, D. (1991). The lippincott manual of nursing practice (5th ed.)
(pp. 210-226). Philadelphia: J. B. Lippincott
Thelan, L. A., & Urden, L. D. (1998). Critical care nursing: diagnosis and
management (3rd ed.). st. Louis, MO:Mosby
u.S. department of health and human services. (1994). Unstable angina:
Diagnosis and management. Rockville, MD: Agency for health care policy
and research.
Domain

Classes

Interventions

2
Physiological : comlexcontd
Care that support
homeostatic regulation

K
Respiratory
manajement
Interventions to
promote airway
patency and gas
exchange

3350
Respiratory monitoring
Definition : collection and analysis of
patien data to ensure air way patency
and adequate gas excange

Activities :

Monitor rate, rhythm, depth and effort of respiration

Note chest movement, watching for symmetry, use of accesory muscles, and
supraclavicular, and intercostal musle retraktion
Monitor for noisy respiration, such as crowing or snoring.
Monitor breathing patterns: bradipnea, tachypnea, hyperventilation,
kussmaul respiration, cheyne stokes, respiration, apneustic, biots
respiration,and ataxic pattern
Palpate for equal lung expansion
Percus anterior and posterior thorax from apices to bases bilaterally
Note location of trachea
Monitor for diaphragmatic muscle fatigue
Auscultate breath sounds, noting areas of decreased / absent ventilation and
presence of adventitious sounds
Determine the need for suctioning by austultating for crackle and ronchi over
major airways
Auscultate lung sounds after treatmens to note result
Monitor PFT values, particularly vital capasity, maximal inspiratory force,
forced expiratory volume in 1 second (FEV 1), and FEV/FVC as available
Monitor mecanical ventilator readings, noting increases in inspiratory
pressures and decreases in tidal volume as appropiate
Monitor for increased retlessness, anxiety, and air hunger
Note changes in SaO2, SvO2, and tidal CO2, and changes in ABG values, as
appropiate
Monitor pattients ability to cough effectively
Note onset, characteristic, and duration chough.
Monitor patients respiratory secretion.
Note onset,characterics,and duration of cough
Monitor patients rescretions
Monitor for dyspnea and events that inprove and worsen it
Monitor forhoarseness and voice changes every hour in patients with facial
burns
Monitor for chest x-ray reports
Open the patient on side, as indicated, to prevent aspiration; logroll if cervical
aspiration suspected
Institute resuscitation efforts, as needed
Institute respiratory therapy treatments (e.g., nebulizer), as needed

Domain
7
Community
Care that supports the
health of the community

Classes

Interventions

C
Community risk
management :
interfention that
assist in detecting
or preventing
health , risks to the
whole community

8880
Environmental risk protection
Definition: preventing and detecting
disease and injury in populations at
risk from environmental hazard

Activities:
Assess environtment for potential and actual risk
Analyze the level of risk associated with the environment (e,g., living habits,
work, atsmosphere, water housing,food, waste, radiation, and violence)
Inform population at risk about the environmental hazart
Monitor incident of illness and injury related to environment standart (e.g.,
environment protection agency (EPA) and occupation safety and health
administration (OSHA) regulation.)
Notify agencies authorized to protect to improve environmental safety
Collaborate with other agencies to improve environmental safety
Advocate for safer environmental designs , protection systems, and use of
protective devices
Support programs to disclose environment hazards
Screen population at risk for evidence of exposure to environment hazards
Participate in data collection related to incidence of exposure to
environmental hazards