B. ANALISA DATANo Data Fokus Problem Etiologi1 DS:

- Ibu mengatakan badan anak masih panasDO:

- Keadaan umum lemah - GCS:6 (E2VxM4)- Kulit teraba hangat- Nadi: 156x/menit, RR:31x/menit, Suhu:38,10C- Leukosit: 26,1 ribu/ul- Balance cairan:+97cc- Deuresis: 1,78cc- Klien terpasang ET+Ventilator- Hasil pemerikdaan Thorak: adanya pneumonia dan efusi bilateral minimal- Hasil pemeriksaan parasitologi tinja ditemukan pseudohifa dan yeast cell.- Hasil pemeriksaan gambaran darah tepi dengan netrofilia absolut dan trombositosis

menyokong proses kronis (gangguan fungsi hati) dan infeksi

Hipertermi(hyperthermia)

Penyakit (pneumonia)

2 DS:- Ibu mengatakan kadang anak batuk

DO:- Keadaan umum lemah - GCS:6 (E2VxM4)- RR:31x/menit, SaO2: 91%- Tampak keluar sputum warna putih jernih pada selang ET- Terdengar suara grok-grok- Aukultasi terdengar ronchi seluruh lapang paru- Terdengar suara gurgling- Hasil pemeriksaan Thorak: adanya efusi bilateral minimal

Pembersihan jalan nafas,

ketidakefektifan(airway

clearance, ineffective)

Peningkatan produksi sputum

(copious secretion)

22

3 DS:-

DO:- Tampak pernafasan cepat dan dangkal- Tampak retraksi dinding dada- Nadi: 156x/menit, RR:31x/menit, SaO2: 91%- Auskultasi terdengar suara whezing pada seluruh lapang paru- PCO2: 36,0mmhg, PO2: 145,0mmhg- VTi: 75, VTe: 54- Perbandingan inpirasi dan ekspirasi 1:2

Pola nafas, ketidakefektifan

(breathing pattern,

ineffective)

Hiperventilasi (hyperventilation)

4 DS : -

DO : - Keadaan umum lemah - Kesadaran somnolen, GCS:6 (E2VxM4)- Nadi: 156x/menit, RR:31x/menit, SaO2: 91%- Hasil AGD: PH: 7,300, BE: -8,5 mmol/l, PCO2: 36,0mmhg, PO2:

145,0mmhg,HCO3: 19,0mmol/l, total CO2: 18,4mmol/l, sat O2:99%- Pasien terpasang ventilator dengan mode PC- Tampak pernafasan cepat dan dangkal- Tampak adanya retraksi dinding dada

Gangguan pertukaran gas(impaired gas

exchange)

Perubahan membran alveolar

kapiler(alveolar-capillary

membrane changes)

5. DS: ibu mengatakan suhu tubuh anak tidak turun-turun

DO:- Suhu:38,10C- Leukosit: 26,1 ribu/ul- Kulit hangat

Sepsis

23

- Hasil pemeriksaan parasitologi tinja ditemukan pseudohifa dan yeast cell.- Hasil pemeriksaan gambaran darah tepi dengan netrofilia absolut dan trombositosis

menyokong proses kronis (gangguan fungsi hati) dan infeksi

C. DIAGNOSA KEPERAWATAN

1. Ketidakefektifan pembersihan jalan nafas b.d peningkatan produksi sputum2. Ketidakefektifan pola nafas b.d hiperventilasi3. Gangguan pertukaran gas b.d Perubahan membran alveolar kapiler4. Hipertermi b.d Penyakit (pneumonia)5. PK: Sepsis berhubungan dengan hipoperfusi sistemik terkait dengan maldistribusi volume sirkulasi akibat respon inflamasi

sistemik yng tidak terkontrol

D. IMPLEMENTATIONIneffective airway clearance related to copious secretion

24

NOC NIC RationalAfter giving nursing care plan as long ..... x 24hours, Patient's secretions are mobilized and airway is maintained free of secretions, as evidenced by clear lung sounds, and normal respiratory rate: 30-40 breaths per minute

1. Assess airway for patency.

2. Assess respirations; note quality, rate, pattern, depth, flaring of nostrils, dyspnea on exertion, evidence of splinting, use of accessory muscles, position for breathing

3. Assess changes in vital signs and temperature.

4. Note presence of sputum; assess quality, color, amount, odor, and consistency.

5. If bedridden, routinely check the patient's position so he or she does not slide down in bed

6. If cough is ineffective, use nasotracheal suctioning as needed

7. Use humidity (humidified O2 or humidifier at bedside)

8. Encourage oral intake of fluids within the limits of cardiac reserve

9. Administer medications (e.g., antibiotics, mucolytic agents, bronchodilators, expectorants) as ordered, noting

1. Maintaining the airway is always the first priority, especially in cases of trauma, acute neurological decompensation, or cardiac arrest

2. Abnormality indicates respiratory compromise.

3. Tachycardia and hypertension may be related to increased work of breathing. Fever may develop in response to retained secretions/atelectasis.

4. May be a result of infection, bronchitis, chronic smoking, and others. A sign of infection is discolored sputum (no longer clear or white); an odor may be present.

5. This may cause the abdomen to compress the diaphragm, which would cause respiratory embarrassment.

6. To remove sputum and mucous plugs.

7. To loosen secretions

8. To prevent drying of secretions

9. To prevent aspiration.

25

effectiveness and side effects.10. If secretions cannot be cleared, anticipate

the need for an artificial airway (intubation)11. Teach family member about environmental

factors that can precipitate respiratory problems

10. To help facilitate removal of tenacious sputum.

11. In addition to adding knowledge

Ineffective breathing pattern related to hyperventilationNOC NIC Rational

After giving nursing care plan as long ..... x 24hours, patient's breathing pattern is maintained as evidenced by: eupnea, normal skin color, and regular respiratory rate/pattern (30-50 breaths per minute)

1. Assess respiratory rate and depth by listening to lung sounds

2. Assess for dyspnea and quantify3. Monitor breathing patterns4. Note muscles used for breathing (e.g.,

sternocleidomastoid, abdominal, diaphragmatic).

5. Note retractions, or flaring of nostrils.

6. Use pulse oximetry to monitor O2 saturation and pulse rate.

1. Respiratory rate and rhythm changes are early warning signs of impending respiratory difficulties.

2. To determine activity tolerance.3. To determine next intervention.4. The accessory muscles of inspiration are not

usually involved in quiet breathing. These include the scalenes (attach to the first two ribs) and the sternocleidomastoid (elevates the sternum).

5. Which would signify an increase in work of breathing.

6. Pulse oximetry is a useful tool to detect changes in oxygenation early on; however, for CO2 levels, end tidal CO2 monitoring or arterial blood gases (ABGs) would need to be obtained.

7. Increasing PaCO2 and decreasing PaO2 are

26

7. Monitor ABGs as appropriate; note changes

8. Assess skin color, temperature, capillary refill; note central versus peripheral cyanosis.

9. Assess presence of sputum for quantity, color, consistency. If the sputum is discolored (no longer clear or white)

10.Assess ability to clear secretions.

11.Position patient with proper body alignment for optimal breathing pattern.

12.Ensure that O2 delivery system is applied to the patient

13.Anticipate the need for intubation and mechanical ventilation if patient is unable to maintain adequate gas exchange with the present breathing pattern.

signs of respiratory failure. As the patient begins to fail, the respiratory rate decreases and PaCO2begins to rise.

8. To detect changes early.

9. An infection may be present.

10. The inability to clear secretions may add to a change in breathing pattern.

11. If not contraindicated, a sitting position allows for good lung excursion and chest expansion.

12. So that the appropriate amount of oxygen is continuously delivered and the patient does not desaturate.

13. Giving continous breath

Impaired gas exchange related to alveolar-capillary membrane changesNOC NIC Rational

27

After giving nursing care plan as long ..... x 24hours, Patient maintains optimal gas exchange as evidenced by normal ABGs and alert responsive mentation or no further reduction in mental status

1. Assess respirations: note quality, rate, pattern, depth, and breathing effort

2. Assess for signs and symptoms of hypoxemia: tachycardia, restlessness, diaphoresis, headache, lethargy, and confusion.

3. Monitor vital signs

4. Monitor arterial blood gases (ABGs) and note changes.

5. Use pulse oximetry to monitor O2 saturation and pulse rate continuously.

6. Assess skin color for development of cyanosis.

7. Monitor effects of position changes on oxygenation (SaO2, ABGs, SvO2, and end tidal CO2)

8. Maintain oxygen administration device as ordered, attempting to maintain O2 saturation at 90% or greater

9. Position with proper body alignment for optimal respiratory excursion (if tolerated, head of bed at 45 degrees).

10. Change patient's position every 2 hours.11. Suction as needed.

1. Both rapid, shallow breathing patterns and hypoventilation affect gas exchange

2. Collapse of alveoli increases physiological shunting.

3. With initial hypoxia and hypercapnia, blood pressure (BP), heart rate, and respiratory rate all rise

4. Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure. 

5. Pulse oximetry is a useful tool to detect changes in oxygenation. O2saturation should be maintained at 90% or greater

6. For cyanosis to be present, 5 gm of hemoglobin must desaturate

7. Putting the most congested lung areas in the dependent position (where perfusion is greatest) potentiates ventilation and perfusion imbalances.

8. To provide for adequate oxygenation.

9. This promotes lung expansion and improves air exchange.

10. This facilitates secretion movement and drainage.

28

12. Anticipate need for intubation and mechanical ventilation if patient is unable to maintain adequate gas exchange.

13. Administer medications as prescribed

14. Explain to family member that the type of oxygen therapy being used and why its maintenance is important.

11. To clear secretions if the patient is unable to effectively clear the airway.

12. Early intubation and mechanical ventilation are recommended to prevent full decompensation of the patient. Mechanical ventilation provides supportive care to maintain adequate oxygenation and ventilation to the patient. 

13. The type depends on the etiologic factors of the problem 

14. Issues related to home oxygen use, storage, or precautions need to be addressed.

Hyperthermia related to illness (pneumonia)NOC NIC Rational

After giving nursing care plan as long ..... x 24hours, patient will be able to resume and maintain normal body temperature as evidence by: Client will be able to report and show manifestations that fever is relieved or controlled through verbatim, temperature of 36.8ᴼC per axilla, respiratory rate of 30-40 breaths per minute, pulse rate of 60- 75 beats per minute, stable blood

1. Assess and monitor client’s temperature and note for presence of chills/ profuse diaphoresis; also note for degree and pattern of occurrence.

2. Adjust and monitor environmental factors like room temperature and bed linens as indicated.

3. Administer antipyretics as prescribed by the physician, utilizing the 10 Rs in giving medication.

4. Provide cooling blanket as indicated

1. Temperature 38.9ᴼC – 41ᴼC may suggest acute infectious disease process. A sustained fever may be due to pneumonia or typhoid fever while a remittent fever may be due to pulmonary infections

2. It could help in reducing hyperthermia

3. Antipyretics acts on the hypothalamus, reducing hyperthermia

4. It is helpful in reducing increased body temperature especially with temperatures of 39.5ᴼC – 40ᴼC

29

pressure, absence of muscular rigidity/ chills and profuse diaphoresis

5. Educate family member of signs and symptoms of hyperthermia and help him identify factors related to occurrence of fever; discuss importance of increased fluid intake to avoid dehydration.

5. Providing health teachings to client could help client cope with disease condition and could help prevent further complications of hyperthermia.

Potential complications: septic shock related to systemic hypoperfusion associated with maldistribution of circulationg volume from an uncontrolled systemic inflammatory response to serve infefction

NOC NIC RationalAfter giving nursing care plan as long ..... x 24hours, patient will not develop septic shock as evidenced not develop septic shock as evidenced by: Systolic B/P equal to or

higher than 90 mm Hg Usual mental status Urine output at least 30

ml/hour Extremities warm and

usual color Capillary refill time less

than 3 seconds Palpable peripheral pulses.

1. Assess for and and report signs and symptoms of septic shock

2. Implement measures to maintain adequate tissue perfusion

3. If signs and symptoms of septic shock occur:a. maintain intravenous fluid therapy as

orderedb. maintain oxygen therapy as orderedc. administer antimicrobials as orderedd. administer vasopressors (e.g. dopamine,

norepinephrine) and/or positive inotropic agents (e.g. dobutamine) as ordered to maintain adequate perfusion pressure and cardiac output

e. prepare client for transfer to critical

1. Prepring for next intervention

2. in order to reduce the risk for septic shock

3. Giving faster interenton to suppress the occurrence of septic

30

care unit and insertion of hemodynamic monitoring devices (e.g. central venous catheter, intra-arterial catheter) and ventilatory support.

31