askep inggris

7/31/2019 askep inggris

1/6

No Diagnoses Planning Implementations Evaluations

Goals Interventions Rationales

1 Impaired gas

exchange related

to effects of

alveolar capillary

membrane

changes

Target of length :

during 3x24 hour

do not happened

damage of

transfer gas

Short target :

during 1x24 hour

difference

ventilate pervusido not happened

With criteria

result of " Normal

Respiration " Po2

mount and

downhill pco2

1. teaching

respiration every

2-4 hours , its

deepness, usage

of breath muscle,

nostril and lobe of

is existence of

coughing

2. auscultation

breath sound

every 2-4 hour

3. heightening. part

of moment head

sleep 30-40 with

head a little

extension

4. give O2 if when

needed

5. collaboration with

1. Evaluatingdegree of

respiration trouble

and disease process

2. Assessing degree of

bronkospasme.

3. Watering down client

for the breathing

4. Improving respiration.

distress omission and

cyanosis referring to

hypoxemia.

5. Secret which jell to

1. teaching

respiration every

2-4 hours , its

deepness, usage

of breath muscle,

nostril and lobe

of is existence of

coughing

2. auscultati

on breath sound

every 2-4 hour

3. Heighteni

ng. part of

moment head

sleep 30-40 with

head a little

extension

4. Giving

O2 if when

needed

S: asphyxia say

still client

O: - client seen

to oppress

- Client still

cough

A: problem not

yet been

overcome

P: interventionin continuing.


2/6

2 Cleanness airway

not effective relate

to the existence of

heaping of secret.

Target of length :

during 3x24 hours

cleanness

effective airway.

Short target :

during 1x24 hours

secret inexistence

with criterion "

breath frequency.

less than 40x /

minute " there no

secret " Negative

Ronci

doctor " Gift

medicine with

indication:

bronchodilator "

Monitor blood gas

analysis and

asymmetry pulse

1. Hear and note

breath voice

2. Monitor

exhalation note

expiration and

inspiration

3. Assist client for

balmy position

(semi fowler )

4. Conduct chest

physiotherapy

when needed

teach to cough

and breath in

represent the root

cause commute for

gas in bronchi

annoyer pressure

CO2 usually downhill

and improving

pressure O2 so that

hypoxemia

1. assessing degree of

bronkospasme

2. expirers below par

(length )

3. watering down client

to breathe

4. secret which jell to

represent the root

cause exhalation

annoyed, suction

required to [release]

5. Collabora

ting with doctor "

Gift medicine

with indication:

bronchodilator "

Monitor blood

gas analysis and

asymmetry pulse

1.Heari

ng and note

breath voice

2. Monit

oring exhalation

note expiration

and inspiration

3. Assis

ting client for

balmy position

( semi fowler )

4. Cond

ucting chest

physiotherapy

S: Client say

cough

O:

- cough still

phlegm

- voice rales

- respiration

25x/ second

A: problem

overcome

some of

P: intervention

in continuing.


3/6

3

Is not effective

exhalation pattern

relate to dyspneu

Target of length :

During 3x24 hours

effective breath

pattern

Short target :

During 1x24 hours

no dyspneu and

no nose lobe

effective after

medication of

suction

5. collaboration

with doctor "

giving medicine

with indication :

inhalers,

antimicrobial and

bronchodilator "

Monitor : blood

gas analysis,

thorax roentgen

1. observation vital

sign every 4

hours

2. Giving oxygen

therapy

according to

indication

3. Arrange semi

position

secret

5. secret a which jell to

represent the root

cause transfer of gas

in breath channel

annoyed. co2

pressure usually

mount and downhill

o2 pressure so that

hypoxemia

1. To knowing client

generality

2. Fulfilling requirement

of oxygen

3. Watering down client

breathe. Can is

when needed

teach to cough

and breath in

effective after

medication of

suction

5. colla

boration with

doctor " giving

medicine with

indication :

inhalers,

antimicrobial and

bronchodilator "

Monitor : blood

gas analysis,

thorax roentgen

1. obser

vation vital sign

every 4 hours

2. Givin

g oxygen therapy

according to

S: Client still

oppress

O:

- visible client

oppress

- cough (+)

A: problem not

yet been

overcome

P: intervention


4/6

4

Change of

Nutrient less than

requirement of

body relate to

Anorexia

Target of length :

During 3x 24

hours requirement

of nutrient fulfilled

Short target :

During 1x24 client

hours do not

anorexia

With criteria

Heavy

increase of

body

4. Collaboration

with doctor:

Giving

bronchodilator,

antikolergenik,

and anti

inflammation

1.

Give the

clarification at

important family

and client of

food to disease

recovering

2.

Teaching client

an ability to eat

downhill of kolaps of

airway activity and

dispneu

4. Medicine which in]

giving can improve

effectively of airway.

1. Giving

information of

purpose of nutrient

add knowledge at

family and client

2. Client

acutely distress

reparatory often

anorexia because

dyspneu , produce

sputum

indication

3. Arran

ge semi position

4. Colla

borating with

doctor:

Giving

bronchodilator,

antikolergenik,

and anti

inflammation

1.

Giving the

clarification atimportant family

and client of food

to disease

recovering

2.

in continuing

S: queasy word

still client

O:

- portion eat

do not finished

- queasy

visible client

A: problem not

yet been

overcome

P: intervention in

continuing.


5/6

Portion eat

finished 3.

give high

calories and

high protein

food and vary

and presented

by food with

small portion

but in a state of

warmness

4.

oral hygiene

consecutively

5.

measure body

heavy

6.

collaboration

craftily nutrient

to increase

amenity in

3. Adding

calorie intake with

mounting passion

eat

4. Aroma

representing one of

the cause the

happening of less

passion eat

5. Good for

determining

requirement ofcalorie

6. Feeding

method which

enough is base to

individual need to

Teaching client

an ability to eat

3.

Giving high

calories and high

protein food and

vary and

presented by

food with small

portion but in a

state of

warmness

4.

conducting oral

hygiene

consecutively

5.

measure body

heavy


6/6

nutrient

digestion,

balance. as

according to

requirement

7.

collaboration

with doctor for

the giving of

vitamin

8.

given oxygen

addition in

appropriate size

measure

collaborations

with doctor

increase maximal

and minimum

requirement

7. vitamin step up

earn lust eat

8. oxygen can balance

co2 in blood so that

can degrade

dyspnue and also

food earn

6.

Collaborating

craftily nutrient to

increase amenity

in nutrient

digestion,

balance. as

according to

requirement

7.

Collaboratingwith doctor for

the giving of

vitamin

8.

giving oxygen

addition in

appropriate size

measurecollaborations

with doctor

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