ASSESSMENT
a. Activity / Rest
Symptoms:
- Exhaustion, fatigue, malaise
- The inability to perform daily activities because of difficulty breathing
- Inability to sleep, need to sleep sitting up high
- Dyspnea at rest or in response to activity or exercise
Signs:
- Fatigue, anxiety, insomnia
- General weakness / loss of muscle mass
b. Circulation
Symptoms:
- Swelling of the lower extremities
Signs:
- Increased blood pressure, increased heart rate / severe tachycardia, dysrhythmias, distended neck veins
- Edema dependent, not associated with heart disease
- Faint heart sound (which is associated with increased AP diameter of the chest)
- The color of skin / mucous membranes: normal or abu-abu/sianosis
- Pallor may indicate anemia
c. Food / fluid
Symptoms:
- Nausea / vomiting, poor appetite / anorexia (emphysema)
- Inability to eat due to respiratory distress
- Losing weight sedentary (emphysema), weight gain showed edema (bronchitis)
Signs:
- Poor skin turgor, edema dependent
- Sweating, drop in body weight, decrease in muscle mass / fat subcutaneously (emphysema)
- Palpitations can cause abdominal hepatomegaly (bronchitis)
d. Hygiene
Symptoms:
- Decreased ability / enhancement needs help doing everyday activities
Signs:
- Cleanliness, bad body odor
e. Breathing
Symptoms:
- Shortness of breath (dyspnea hidden emergence as prominent symptoms in emphysema), particularly at work, the weather or recurrent episodes of difficult breathing (asthma), sense of chest pressure, inability to breathe (asthma)
- "Air hunger" chronic
- Shape settled with the production of sputum every day (especially when awake) for at least 3 consecutive months each year at least 2 years. Sputum production (green, white and yellow) can be a great deal (chronic bronchitis)
- Episode intermittent cough is usually not productive at this early stage although it can occur productive (emphysema)
- History of recurrent pneumonia: exposure to chemical pollution / respiratory irritants in the long term (eg, cigarette smoke) or dust / smoke (eg, abscess, or coal dust, sawdust)
- Factors the family and descendants, eg., Deficiency of alpha-anti-trypsin (emphysema)
- The use of oxygen at night or continuously
Signs:
- Respiratory: usually fast, slow, use of accessory muscles
- Chest: hyperinflation with elevated AP diameter, minimal diaphragm movement
- The sound of breath: may dim with expiratory wheezing (emphysema), spreads, soft or krekels, crackles, wheezing lungs throughout the area.
- Percussion: hiperesonan the lung area
- Color: pale with cyanotic lips and nail beds.
f. Security
Symptoms:
- History of allergic reaction or are sensitive to substances / environmental factors
- The presence / recurrence of infection
- Redness / sweating (asthma)
g. Sexuality
Symptoms:
- Decreased libido
h. Social Interaction
Symptoms:
- The relationship of dependence, lack of support systems, improved inability / old disease
Signs:
- Inability to / makes maintaining respiratory sounds
- The limited physical mobility, abnormalities with family members and
i. Counseling / Learning
Symptoms:
- The use / abuse of drugs breathing, difficulty stopping smoking, regular alcohol use, failure to improve.
Priority Care
1. Maintain airway patency
2. Help measures to facilitate the exchange of gases
3. Increasing nutrient inputs
4. Prevent complications, slow down deterioration
5. Provide information about disease process / prognosis and treatment programs
Nursing Diagnosis
1. Ineffective airway b / d bronchospasm, increased production of secretions, retained secretions, thick, viscous secretions d / d statements difficulty breathing, changes in depth / speed of breathing, use of accessory muscles, abnormal breath sounds, eg., Crackles, wheezing, krekels ; cough (settled) with / without sputum production
Criteria results:
- Maintain a patent airway with breath sounds clean and clear.
- Demonstrate behaviors to improve airway clearance, eg., Cough effectively and remove secretions
Rational Intervention
Independent:
• Auscultation of breath sounds, note the presence of an additional breath sounds, eg., Wheezing, krekels, rhonchi
• Assess / monitor respiratory frequency, record the ratio of inspiration / expiration
• Note the degree of dyspnea, anxiety, respiratory distress, use of accessory muscles of breath
• Place / adjust the position of the patient as comfortable as possible, eg., Elevation of the head of the bed 15-30 °, sitting on the back of the bed.
• Keep the ambient air / minimize pollution of the environment, eg., Dust, smoke, etc..
• Help abdominal breathing exercises or lip
• Increase fluid intake to 3000 ml / day as tolerated heart. Provide / suggest drinking warm water.
Collaboration:
• Give medications as indicated, eg., Bronchodilator
• Some degree of bronchial spasms occur with airway obstruction and may / not manifested adanyan advertisius breath sounds.
• Tachypnea is usually present in some degree and DAPT found on admission or during stress / presence of acute infectious process.
• Respiratory dysfunction is variable depending on the stage of the process leading to acute hospitalization.
• bed head elevation facilitates respiratory function by using gravity.
• Originator type of respiratory allergic reactions to triggers of acute episodes.
• Give the patient a few ways to cope with and control dyspnea and lower traps air
• Hydration helps decrease the viscosity of secretions, the use of warm fluids can decrease bronchial spasms.
• relaxes smooth muscle spasms and lower airway, wheezing, and mucous production.
2. Damage to gas exchange b / d of oxygen supply disruption (airway obstruction) by secretion, bronchospasm, air traps, damage alveoli d / d dyspnea, confusion, restlessness, inability to secrete abnormal secretions GDA values (hypoxia and hiperkapnea), changes in vital signs , decreased tolerance for activity.
Criteria results:
- Demonstrate improved ventilation and adequate tissue oxygenation with GDA in the normal range and free of symptoms of respiratory distress.
- Participate in a treatment program in the level of ability / situation.
Rational Intervention
• Assess frequency, depth of breathing, note the use of accessory muscles, breathing lips.
• Elevate head of bed, help the client to choose a position that is easy to breathe, breathe in slowly push
• Assess / watch regularly the skin and mucous membrane color
• Encourage issued sputum, suction if indicated
• Auscultation of breath sounds, cata area decreased air / additional sound
• Monitor vital signs and cardiac rhythm
Collaboration
• Give oxygen as indicated
• Give suppressor CNS (anti-anxiety sedative or narcotic) carefully as indicated • Useful in the evaluation of the degree of respiratory distress / chronic disease process
• Delivery of oxygen can be improved by a high seating position and breathing exercises to reduce lung collapse
• Cyanosis may be peripheral (seen on the nails)
• Sputum lumpy, thick secretions and the many disorders are a major source of gas exchange in small airways. Sucking needed when coughing ineffective
• The sound of breathing may be faint because of decreased air flow or consolidation area, any identifying bronchospasm
• Tachycardia, dysrhythmias and decreased td can show the effects of systemic hypoxemia on cardiac function
• Can fix / prevent bad hypoxic
• To control anxiety / anxious that increase consumption / oxygen demand
3. Changes in nutrition less than body requirements b / d dyspnea, medication side effects, production of sputum, anorexia, nausea / vomiting d / d weight loss, loss of muscle mass, poor muscle tone, weakness, reluctance to eat.
Kriteri results:
- Indicates BB meningkatkat
- Achieve goals with normal laboratory values and free signs of malnutrition.
- Conducting behavioral / lifestyle changes to menngkatkan and maintain proper BB.
Rational Intervention
• Record the nutritional status of patients on admission, noted skin turgor, and the degree of deficiency BB BB, inability to swallow.
• Ensure regular diet in patients who liked / disliked
• Monitor income / expenditures and BB periodically.
• Investigate anorexia, nausea and vomiting. Note the possibility of a drug, watch the frequency, volume, consistency of stool.
• Provide frequent rest periods.
• Provide oral care
• Avoid foods and drinks gas penghasi carbonate. Avoid foods that are very hot and very cold
• Encourage eating little but often with food TKTP
• Motivate people closest to bring food from home to share with patients unless contraindicated
Collaboration
• Refer to a dietitian to determine the composition of the diet.
• Assess / Observation Laboratory examinations value, eg., Amino acid profile, iron, glucose, liver function tests, and electrolytes. Give vitamins / minerals / electrolytes as indicated • Useful in defining the degree / extent of the problem and the choice of appropriate interventions.
• Assist in identifying specific needs. Consideration of the individual's desire to improve dietary input.
• Useful in measuring the effectiveness of nutritional and fluid support.
• It can affect dietary choices and identify solutions to improve nutrient intake.
• Helps save energy, particularly if the increased metabolic demands during a fever.
• Reduce discomfort for the rest of sputum / drugs that stimulate the patient vomit.
• It can produce abdominal distention that interferes with the movement of the diaphragm and abdominal breathing. Extreme temperatures can increase coughing spasms
• Maximizing nutrient inputs without weakness, decrease gastric irritation.
• Create a more normal social environment during meals and helps meet personal needs.
• Provide assistance in planning a diet with adequate nutrition
• Evaluate / overcome deficiencies and monitor the effectiveness of nutritional therapy
4. High risk of infection b / d ketidakadekuatan main defense (decrease cilia work, persistence secretions), inadequate immunity (tissue damage and increased exposure to the environment, the process of chronic disease and malnutrition.
Criteria results:
- Patients will identify interventions to prevent or reduce the risk of infection
- Changes in lifestyle to promote a comfortable environment
Rational Intervention
Independent:
• Assess and monitor body temperature
• Assess the importance of breathing exercises, effective cough, frequent position changes and adequate fluid intake
• Observation of color, character and odor of sputum
• Discuss the need for adequate nutrition
Collaboration:
• Obtain specimens with cough and sputum suction for gram staining, / culture / sensitivity
• Provide anti-microbial as indicated
• Fever may occur because of infection or dehydration
• This activity increased mobilization and expenditure secretions to decrease the risk of lung infections
• smelling discharge, yellow or greenish indicate a lung infection
• Malnutrition can affect general health and lower resistance to infections
• stiffened to identify the causative organisms and susceptibility to a variety of anti-microbial
• Can be given to specific organisms identified by culture and sensitivity or administered prophylactically for high-risk
5. Lack of knowledge about disease conditions and treatment actions b / d less information / resources that knows no d / d questions about information, not accurate follow instructions
Criteria results:
- Declare an understanding of the condition / disease process and actions
- Change in lifestyle and participating in treatment programs
Rational Intervention
• Explain the process of individual disease
• Instruct the rationale for the exercise of breath, cough effectively, and exercise general condition
• Discuss the importance of avoiding people who are active respiratory infection
• Assess the effect of the dangers of smoking and smoking meghentikan advise the patient and or significant others
• Discuss respiratory medications, side effects and unwanted reactions
• Show / teaching inhaler technique use • Reduce anxiety and can lead to improved participation in treatment plan
• Shortness of breath mouth and stomach (abdominal) strengthens the respiratory muscles, helps minimize small airway collapse. Exercise common conditions increase activity tolerance, muscle strength and sense of well-
• Reduce exposure and incidence of getting upper respiratory infections
• Cessation of smoking can hinder the progress of PPOM.
• cudgel for the patient to understand the difference between intrusive and harmful side effects
• Provision of appropriate medications increases its effectiveness.
a. Activity / Rest
Symptoms:
- Exhaustion, fatigue, malaise
- The inability to perform daily activities because of difficulty breathing
- Inability to sleep, need to sleep sitting up high
- Dyspnea at rest or in response to activity or exercise
Signs:
- Fatigue, anxiety, insomnia
- General weakness / loss of muscle mass
b. Circulation
Symptoms:
- Swelling of the lower extremities
Signs:
- Increased blood pressure, increased heart rate / severe tachycardia, dysrhythmias, distended neck veins
- Edema dependent, not associated with heart disease
- Faint heart sound (which is associated with increased AP diameter of the chest)
- The color of skin / mucous membranes: normal or abu-abu/sianosis
- Pallor may indicate anemia
c. Food / fluid
Symptoms:
- Nausea / vomiting, poor appetite / anorexia (emphysema)
- Inability to eat due to respiratory distress
- Losing weight sedentary (emphysema), weight gain showed edema (bronchitis)
Signs:
- Poor skin turgor, edema dependent
- Sweating, drop in body weight, decrease in muscle mass / fat subcutaneously (emphysema)
- Palpitations can cause abdominal hepatomegaly (bronchitis)
d. Hygiene
Symptoms:
- Decreased ability / enhancement needs help doing everyday activities
Signs:
- Cleanliness, bad body odor
e. Breathing
Symptoms:
- Shortness of breath (dyspnea hidden emergence as prominent symptoms in emphysema), particularly at work, the weather or recurrent episodes of difficult breathing (asthma), sense of chest pressure, inability to breathe (asthma)
- "Air hunger" chronic
- Shape settled with the production of sputum every day (especially when awake) for at least 3 consecutive months each year at least 2 years. Sputum production (green, white and yellow) can be a great deal (chronic bronchitis)
- Episode intermittent cough is usually not productive at this early stage although it can occur productive (emphysema)
- History of recurrent pneumonia: exposure to chemical pollution / respiratory irritants in the long term (eg, cigarette smoke) or dust / smoke (eg, abscess, or coal dust, sawdust)
- Factors the family and descendants, eg., Deficiency of alpha-anti-trypsin (emphysema)
- The use of oxygen at night or continuously
Signs:
- Respiratory: usually fast, slow, use of accessory muscles
- Chest: hyperinflation with elevated AP diameter, minimal diaphragm movement
- The sound of breath: may dim with expiratory wheezing (emphysema), spreads, soft or krekels, crackles, wheezing lungs throughout the area.
- Percussion: hiperesonan the lung area
- Color: pale with cyanotic lips and nail beds.
f. Security
Symptoms:
- History of allergic reaction or are sensitive to substances / environmental factors
- The presence / recurrence of infection
- Redness / sweating (asthma)
g. Sexuality
Symptoms:
- Decreased libido
h. Social Interaction
Symptoms:
- The relationship of dependence, lack of support systems, improved inability / old disease
Signs:
- Inability to / makes maintaining respiratory sounds
- The limited physical mobility, abnormalities with family members and
i. Counseling / Learning
Symptoms:
- The use / abuse of drugs breathing, difficulty stopping smoking, regular alcohol use, failure to improve.
Priority Care
1. Maintain airway patency
2. Help measures to facilitate the exchange of gases
3. Increasing nutrient inputs
4. Prevent complications, slow down deterioration
5. Provide information about disease process / prognosis and treatment programs
Nursing Diagnosis
1. Ineffective airway b / d bronchospasm, increased production of secretions, retained secretions, thick, viscous secretions d / d statements difficulty breathing, changes in depth / speed of breathing, use of accessory muscles, abnormal breath sounds, eg., Crackles, wheezing, krekels ; cough (settled) with / without sputum production
Criteria results:
- Maintain a patent airway with breath sounds clean and clear.
- Demonstrate behaviors to improve airway clearance, eg., Cough effectively and remove secretions
Rational Intervention
Independent:
• Auscultation of breath sounds, note the presence of an additional breath sounds, eg., Wheezing, krekels, rhonchi
• Assess / monitor respiratory frequency, record the ratio of inspiration / expiration
• Note the degree of dyspnea, anxiety, respiratory distress, use of accessory muscles of breath
• Place / adjust the position of the patient as comfortable as possible, eg., Elevation of the head of the bed 15-30 °, sitting on the back of the bed.
• Keep the ambient air / minimize pollution of the environment, eg., Dust, smoke, etc..
• Help abdominal breathing exercises or lip
• Increase fluid intake to 3000 ml / day as tolerated heart. Provide / suggest drinking warm water.
Collaboration:
• Give medications as indicated, eg., Bronchodilator
• Some degree of bronchial spasms occur with airway obstruction and may / not manifested adanyan advertisius breath sounds.
• Tachypnea is usually present in some degree and DAPT found on admission or during stress / presence of acute infectious process.
• Respiratory dysfunction is variable depending on the stage of the process leading to acute hospitalization.
• bed head elevation facilitates respiratory function by using gravity.
• Originator type of respiratory allergic reactions to triggers of acute episodes.
• Give the patient a few ways to cope with and control dyspnea and lower traps air
• Hydration helps decrease the viscosity of secretions, the use of warm fluids can decrease bronchial spasms.
• relaxes smooth muscle spasms and lower airway, wheezing, and mucous production.
2. Damage to gas exchange b / d of oxygen supply disruption (airway obstruction) by secretion, bronchospasm, air traps, damage alveoli d / d dyspnea, confusion, restlessness, inability to secrete abnormal secretions GDA values (hypoxia and hiperkapnea), changes in vital signs , decreased tolerance for activity.
Criteria results:
- Demonstrate improved ventilation and adequate tissue oxygenation with GDA in the normal range and free of symptoms of respiratory distress.
- Participate in a treatment program in the level of ability / situation.
Rational Intervention
• Assess frequency, depth of breathing, note the use of accessory muscles, breathing lips.
• Elevate head of bed, help the client to choose a position that is easy to breathe, breathe in slowly push
• Assess / watch regularly the skin and mucous membrane color
• Encourage issued sputum, suction if indicated
• Auscultation of breath sounds, cata area decreased air / additional sound
• Monitor vital signs and cardiac rhythm
Collaboration
• Give oxygen as indicated
• Give suppressor CNS (anti-anxiety sedative or narcotic) carefully as indicated • Useful in the evaluation of the degree of respiratory distress / chronic disease process
• Delivery of oxygen can be improved by a high seating position and breathing exercises to reduce lung collapse
• Cyanosis may be peripheral (seen on the nails)
• Sputum lumpy, thick secretions and the many disorders are a major source of gas exchange in small airways. Sucking needed when coughing ineffective
• The sound of breathing may be faint because of decreased air flow or consolidation area, any identifying bronchospasm
• Tachycardia, dysrhythmias and decreased td can show the effects of systemic hypoxemia on cardiac function
• Can fix / prevent bad hypoxic
• To control anxiety / anxious that increase consumption / oxygen demand
3. Changes in nutrition less than body requirements b / d dyspnea, medication side effects, production of sputum, anorexia, nausea / vomiting d / d weight loss, loss of muscle mass, poor muscle tone, weakness, reluctance to eat.
Kriteri results:
- Indicates BB meningkatkat
- Achieve goals with normal laboratory values and free signs of malnutrition.
- Conducting behavioral / lifestyle changes to menngkatkan and maintain proper BB.
Rational Intervention
• Record the nutritional status of patients on admission, noted skin turgor, and the degree of deficiency BB BB, inability to swallow.
• Ensure regular diet in patients who liked / disliked
• Monitor income / expenditures and BB periodically.
• Investigate anorexia, nausea and vomiting. Note the possibility of a drug, watch the frequency, volume, consistency of stool.
• Provide frequent rest periods.
• Provide oral care
• Avoid foods and drinks gas penghasi carbonate. Avoid foods that are very hot and very cold
• Encourage eating little but often with food TKTP
• Motivate people closest to bring food from home to share with patients unless contraindicated
Collaboration
• Refer to a dietitian to determine the composition of the diet.
• Assess / Observation Laboratory examinations value, eg., Amino acid profile, iron, glucose, liver function tests, and electrolytes. Give vitamins / minerals / electrolytes as indicated • Useful in defining the degree / extent of the problem and the choice of appropriate interventions.
• Assist in identifying specific needs. Consideration of the individual's desire to improve dietary input.
• Useful in measuring the effectiveness of nutritional and fluid support.
• It can affect dietary choices and identify solutions to improve nutrient intake.
• Helps save energy, particularly if the increased metabolic demands during a fever.
• Reduce discomfort for the rest of sputum / drugs that stimulate the patient vomit.
• It can produce abdominal distention that interferes with the movement of the diaphragm and abdominal breathing. Extreme temperatures can increase coughing spasms
• Maximizing nutrient inputs without weakness, decrease gastric irritation.
• Create a more normal social environment during meals and helps meet personal needs.
• Provide assistance in planning a diet with adequate nutrition
• Evaluate / overcome deficiencies and monitor the effectiveness of nutritional therapy
4. High risk of infection b / d ketidakadekuatan main defense (decrease cilia work, persistence secretions), inadequate immunity (tissue damage and increased exposure to the environment, the process of chronic disease and malnutrition.
Criteria results:
- Patients will identify interventions to prevent or reduce the risk of infection
- Changes in lifestyle to promote a comfortable environment
Rational Intervention
Independent:
• Assess and monitor body temperature
• Assess the importance of breathing exercises, effective cough, frequent position changes and adequate fluid intake
• Observation of color, character and odor of sputum
• Discuss the need for adequate nutrition
Collaboration:
• Obtain specimens with cough and sputum suction for gram staining, / culture / sensitivity
• Provide anti-microbial as indicated
• Fever may occur because of infection or dehydration
• This activity increased mobilization and expenditure secretions to decrease the risk of lung infections
• smelling discharge, yellow or greenish indicate a lung infection
• Malnutrition can affect general health and lower resistance to infections
• stiffened to identify the causative organisms and susceptibility to a variety of anti-microbial
• Can be given to specific organisms identified by culture and sensitivity or administered prophylactically for high-risk
5. Lack of knowledge about disease conditions and treatment actions b / d less information / resources that knows no d / d questions about information, not accurate follow instructions
Criteria results:
- Declare an understanding of the condition / disease process and actions
- Change in lifestyle and participating in treatment programs
Rational Intervention
• Explain the process of individual disease
• Instruct the rationale for the exercise of breath, cough effectively, and exercise general condition
• Discuss the importance of avoiding people who are active respiratory infection
• Assess the effect of the dangers of smoking and smoking meghentikan advise the patient and or significant others
• Discuss respiratory medications, side effects and unwanted reactions
• Show / teaching inhaler technique use • Reduce anxiety and can lead to improved participation in treatment plan
• Shortness of breath mouth and stomach (abdominal) strengthens the respiratory muscles, helps minimize small airway collapse. Exercise common conditions increase activity tolerance, muscle strength and sense of well-
• Reduce exposure and incidence of getting upper respiratory infections
• Cessation of smoking can hinder the progress of PPOM.
• cudgel for the patient to understand the difference between intrusive and harmful side effects
• Provision of appropriate medications increases its effectiveness.
