Name : Friskilla Elvita Handayani

NIM : 50120080016
School of Nursing ETP ‘08
Universitas Pelita Harapan

Critical Event Analysis

I. Health History
Ms. BR, 17 years old. She came to the hospital in March 28th, 2009 with medical
diagnose Dyspepsia. On April 1st, 2009 She was complain about chest pain. The
other complained is about when she had chest pained, her breathing is narrow
too.

II. Physical Examination

a. Subjective data
Past history: Patient said that she has nausea, chest pain, and
breathing narrow
b. Objective data
Inspection
She uses auxiliary tool Oxygen tube
Palpation
BP : 110/70 mmHg
T : 36.6° C
P : 84 x bpm
RR : 26 x bpm
Chest pain scale: 6 (reasonable pain)
Medical history: Asthma
Diet: Oral
Nutrition: Good
Elimination: Good

III. Nursing Diagnosis

 - Ineffective airway clearance related to secrete accumulation and
artificial breathing pathway, which manifested by RR: 26x/ min and using
Oxygen tube.
- Pain pertaining to chest related to breathing narrow she’s using Oxygen
Tube

IV. Nursing Intervention/Planning

a. Ineffective airway clearance
Objective/goal: patient can breathe effectively
Criteria outcomes:
- There is no accumulation in airway passage
- The respiration rate in normal range: 16-20 bpm
- Patient feel relax in 1 day
Nursing Intervention & Rational:
- Explain the patient’s condition to her family about the nursing intervention
R/ the family know the patient’s condition and be cooperative to
achieve the goal’s treatment
- Use Oxygen tube when she is need it
R/ to maintain the oxygen flow
- Arrange a good positions for her on the bed
R/ to keep her body feels relax
- Detect the breathing pathway insertion, in time of need
R/ to maintain the effective breathing pathway
b. Pain
Objective/goal: Patient will not pain anymore
Criteria Outcomes:
- Give explanation about patient’s condition to his family about
nursing intervention
R/ the family know the patient’s condition and to be cooperative to
achieve the
goal’s treatment
- Teach technique of relaxation
R/ to control patient’s respiration rhythm
- Organize the environment: the temperature, bed position
R/ to make the patient relax and reduce pain
 - Checking vital sign
R/ make sure her vital sign still normal

V. Nursing Implementation
1. Ineffective airway clearance
- Giving explanation about patient’s condition to her family about the
nursing intervention
- Observing gas (Oxygen saturation)
- Arrange a good position for her on the bed
- Control her breathing pathway
2. Pain
- Giving explanation about patient’s condition to her family about the
nursing intervention
- Teaching technique of relaxation
- Organizing the environment: temperature. Bed position
- Checking the vital sign

VI. Evaluation
a. Ineffective breathing pattern
- Patient shows effective breathing pattern in 30 min
- She doesn’t use oxygen after 2 hours
b. Pain
- Pain has reduced in 1 hour
- Patient feel relax