No 1

Diagnoses Impaired gas exchange related to effects of alveolar capillary membrane changes Short target : during 1x24 hour difference ventilate pervusi do not happened With criteria result of " Normal Respiration " Po2 mount and downhill pco2 Goals Target of length : during 3x24 hour do not happened damage of transfer gas

Planning Interventions 1. teaching respiration every 2-4 hours , its deepness, usage of breath muscle, nostril and lobe of is existence of coughing

Implementations

Evaluations S: asphyxia say still client O: - client seen to oppress - Client still cough A: problem not yet been overcome P: intervention in continuing.

1.

Rationales Evaluating degree of respiration trouble and disease process

1.

teaching

respiration every 2-4 hours , its deepness, usage of breath muscle, nostril and lobe of is existence of coughing

2.
2. auscultation breath sound every 2-4 hour 3. heightening. part of moment head sleep 30-40 with head a little extension 3. Watering down client for the breathing 2. Assessing degree of bronkospasme.

auscultati

on breath sound every 2-4 hour

3.

Heighteni

ng. part of moment head sleep 30-40 with head a little extension

4. give O2 if when
needed

4. Improving respiration.
distress omission and cyanosis referring to hypoxemia.

4.

Giving

O2 if when needed

5. collaboration with

5. Secret which jell to

doctor " Gift medicine with indication: bronchodilator " Monitor blood gas analysis and asymmetry pulse

represent the root cause commute for gas in bronchi annoyer pressure CO2 usually downhill and improving pressure O2 so that hypoxemia

5.

Collabora

ting with doctor " Gift medicine with indication: bronchodilator " Monitor blood gas analysis and asymmetry pulse S: Client say

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

1. Hear and note breath voice 2. Monitor exhalation note expiration and inspiration

1. assessing degree of bronkospasme

1.

Heari

cough O: - cough still phlegm - voice rales - respiration 25x/ second A: problem overcome some of P: intervention in continuing.

2. expirers below par

(length )

ng and note breath voice

2.

Monit

oring exhalation note expiration 3. watering down client to breathe and inspiration

3. Assist client for

balmy position (semi fowler ) 4. Conduct chest physiotherapy when needed teach to cough and breath in

3.

Assis

ting client for 4. secret which jell to represent the root cause exhalation annoyed, suction required to [release] balmy position ( semi fowler )

4.

Cond

ucting chest physiotherapy

effective after medication of suction

secret

when needed teach to cough and breath in effective after

5. collaboration
with doctor " giving medicine with indication : inhalers, antimicrobial and bronchodilator " Monitor : blood gas analysis, thorax roentgen Is not effective 3 exhalation pattern relate to dyspneu Target of length : During 3x24 hours effective breath pattern 2. Giving oxygen Short target : During 1x24 hours no dyspneu and no nose lobe therapy according to indication 3. Arrange semi position 1. observation vital sign every 4 hours

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

medication of suction 5. colla boration with doctor " giving medicine with indication : inhalers, antimicrobial and bronchodilator " Monitor : blood

1. To knowing client generality

gas analysis, thorax roentgen 1. obser

S: Client still oppress O: - visible client oppress - cough (+) A: problem not yet been overcome P: intervention

2. Fulfilling requirement of oxygen

vation vital sign every 4 hours 2. Givin

3. Watering down client breathe. Can is

g oxygen therapy according to

downhill of kolaps of airway activity and dispneu 4. Collaboration with doctor: Giving bronchodilator, antikolergenik, and anti inflammation Change 4 requirement body relate Anorexia of 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. Medicine which in] giving can improve effectively of airway.

indication 3. Arran ge semi position

in continuing

4.
doctor: Giving

Colla

borating with

bronchodilator, antikolergenik, Nutrient less than of to

1.
Give the clarification at important family and client of food to disease recovering

1.

Giving

and anti inflammation

S: queasy word still client O: - portion eat do not finished - queasy visible client A: problem not yet been overcome P: intervention in continuing.

information of purpose of nutrient add knowledge at family and client

1.
Giving the clarification at

2.
Teaching client an ability to eat

2.

Client

important family and client of food to disease recovering

acutely distress reparatory often anorexia because dyspneu , produce sputum

2.

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

Teaching client

3.

Adding

an ability to eat

calorie intake with mounting passion eat

3.
Giving high calories and high protein food and vary and

4.

Aroma

presented by food with small portion but in a state of warmness

representing one of the cause the happening of less passion eat

5. measure body heavy 6. collaboration craftily nutrient to increase amenity in

5.

Good for

4.
conducting oral hygiene consecutively

determining requirement of calorie

6.

Feeding 5. measure body heavy

method which enough is base to individual need to

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

6.
Collaborating craftily nutrient to increase amenity in nutrient

7.

vitamin step up earn lust eat

digestion, balance. as according to requirement

8. oxygen can balance co2 in blood so that can degrade dyspnue and also food earn

7.
Collaborating with doctor for the giving of vitamin

8.
giving oxygen addition in appropriate size measure collaborations with doctor