Bersihan Jalan Nafas Tidak Efektif

Bersihan Jalan Nafas Tidak Efektif
BATASAN KARAKTERISTIK
- Dispneu, Penurunan suara nafas
- Orthopneu
- Cyanosis
- Kelainan suara nafas (rales, wheezing)
- Kesulitan berbicara
- Batuk, tidak efekotif atau tidak ada
- Mata melebar
- Produksi sputum
- Gelisah
- Perubahan frekuensi dan irama nafas
FAKTOR YANG BERHUBUNGAN
- Lingkungan : merokok, menghirup asap rokok, perokok pasif-POK, infeksi
- Fisiologis : disfungsi neuromuskular, hiperplasia dinding bronkus, alergi jalan nafas, asma.
- Obstruksi jalan nafas : spasme jalan nafas, sekresi tertahan, banyaknya mukus, jalan nafas buatan,
sekresi bronkus, eksudat di alveolus, benda asing di jalan nafas.
NOC LABEL :
- Respiratory position : Ventilation
- Respiratory position : Airway patency
- Aspiration Control

NOC INDICATOR
- Mendemonstrasikan batuk efektif dan suara nafas yang bersih, tidak ada sianosis dan dyspneu (mampu
mengeluarkan sputum, mampu bernafas dengan mudah, tidak ada pursed lips)
- Menunjukkan jalan nafas yang paten (klien tidak merasa tercekik, irama nafas, frekuensi pernafasan
dalam rentang normal, tidak ada suara nafas abnormal)
- Mampu mengidentifikasikan dan mencegah bourgeois yang dapat menghambat jalan nafas

NIC
Airway suction
- Pastikan kebutuhan oral / tracheal suctioning
- Auskultasi suara nafas sebelum dan sesudah suctioning.
- Informasikan pada klien dan keluarga tentang suctioning
- Minta klien nafas dalam sebelum suction dilakukan.
- Berikan O2 dengan menggunakan nasal untuk memfasilitasi suksion nasotrakeal
- Gunakan alat yang steril sitiap melakukan tindakan
- Anjurkan pasien untuk istirahat dan napas dalam setelah kateter dikeluarkan dari nasotrakeal
- Monitor position oksigen pasien
- Ajarkan keluarga bagaimana cara melakukan suksion
- Hentikan suksion dan berikan oksigen apabila pasien menunjukkan bradikardi, peningkatan saturasi O2,
dll.

Airway Management
- Buka jalan nafas, guanakan teknik chin lift atau utter thrust bila perlu
- Posisikan pasien untuk memaksimalkan ventilasi
- Identifikasi pasien perlunya pemasangan alat jalan nafas buatan
- Pasang mayo bila perlu
- Lakukan fisioterapi pappa jika perlu
- Keluarkan sekret dengan batuk atau suction
- Auskultasi suara nafas, catat adanya suara tambahan
- Lakukan suction pada mayo
- Berikan bronkodilator bila perlu
- Berikan pelembab udara Kassa basah NaCl Lembab

- Atur intake untuk cairan mengoptimalkan keseimbangan.
- Monitor respirasi dan position O2
Gangguan Pertukaran Gas
Batasan karakteristik :
- Gangguan penglihatan
- Penurunan CO2
- Takikardi
- Hiperkapnia

- Keletihan
- Somnolen
- Iritabilitas
- Hypoxia
- Kebingungan
- Dyspnoe
- Nasal faring
- AGD Normal
- Sianosis
- Warna kulit abnormal (pucat, kehitaman)
- Hipoksemia
- Hiperkarbia
- Sakit kepala ketika bangun
- Frekuensi dan kedalaman nafas abnormal
Faktor faktor yang berhubungan :
- ketidakseimbangan perfusi ventilasi
- perubahan membran kapiler-alveolar

NOC Label:
- Respiratory Status : Gas exchange

- Respiratory Status : ventilation
- Vital Sign Status
Kriteria Hasil :
- Mendemonstrasikan peningkatan ventilasi dan oksigenasi yang adekuat
- Memelihara kebersihan paru paru dan bebas dari tanda tanda distress pernafasan
- Mendemonstrasikan batuk efektif dan suara nafas yang bersih, tidak ada sianosis dan dyspneu
(mampu mengeluarkan sputum, mampu bernafas dengan mudah, tidak ada pursed lips)
- Tanda tanda vital dalam rentang normal
NIC :
Airway Management
 Buka jalan nafas, guanakan teknik chin lift atau utter thrust bila perlu
 Posisikan pasien untuk memaksimalkan ventilasi
 Identifikasi pasien perlunya pemasangan alat jalan nafas buatan
 Pasang mayo bila perlu
 Lakukan fisioterapi pappa jika perlu
 Keluarkan sekret dengan batuk atau suction
 Auskultasi suara nafas, catat adanya suara tambahan
 Lakukan suction pada mayo
 Berika bronkodilator bial perlu
 Barikan pelembab udara

 Atur intake untuk cairan mengoptimalkan keseimbangan.
 Monitor respirasi dan position O2
Respiratory Monitoring
 Monitor rata – rata, kedalaman, irama dan usaha respirasi
 Catat pergerakan dada,amati kesimetrisan, penggunaan otot tambahan, retraksi otot
supraclavicular dan intercostal
 Monitor suara nafas, seperti dengkur
 Monitor pola nafas : bradipena, takipenia, kussmaul, hiperventilasi, cheyne stokes, biot
 Catat lokasi trakea
 Monitor kelelahan otot diagfragma (gerakan paradoksis)
 Auskultasi suara nafas, catat area penurunan / tidak adanya ventilasi dan suara tambahan
 Tentukan kebutuhan suction dengan mengauskultasi crakles dan ronkhi pada jalan napas utama
 auskultasi suara paru setelah tindakan untuk mengetahui hasilnya

Perubahan kebutuhan nutrisi kurang dari kebutuhan
Tujuan: Menunjukkan berat badan meningkat mencapai tujuan dengan nilai laboratoriurn normal dan
bebas tanda malnutrisi. Melakukan perubahan pola hidup untuk meningkatkan dan mempertahankan
berat badan yang tepat.
Intervensi:
a. Catat status nutrisi paasien: turgor kulit, timbang berat badan, integritas mukosa mulut, kemampuan

menelan, adanya bising usus, riwayat mual/rnuntah atau diare.
Rasional: berguna dalam mendefinisikan derajat masalah dan intervensi yang tepat.
b. Kaji pola diet pasien yang disukai/tidak disukai.
Rasional: Membantu intervensi kebutuhan yang spesifik, meningkatkan intake diet pasien.
c. Monitor intake dan output secara periodik.
Rasional: Mengukur keefektifan nutrisi dan cairan.
d. Catat adanya anoreksia, mual, muntah, dan tetapkan jika ada hubungannya dengan medikasi. Awasi
frekuensi, volume, konsistensi Buang Air Besar (BAB).
Rasional: Dapat menentukan jenis diet dan mengidentifikasi pemecahan masalah untuk meningkatkan
intake nutrisi.
e. Anjurkan bedrest.
Rasional: Membantu menghemat energi khusus saat demam terjadi peningkatan metabolik.
f. Lakukan perawatan mulut sebelum dan sesudah tindakan pernapasan.
Rasional: Mengurangi rasa tidak enak dari sputum atau obat-obat yang digunakan yang dapat
merangsang muntah.
g. Anjurkan makan sedikit dan sering dengan makanan tinggi protein dan karbohidrat.
Rasional: Memaksimalkan intake nutrisi dan menurunkan iritasi gaster.
h. Rujuk ke ahli gizi untuk menentukan komposisi diet.
Rasional: Memberikan bantuan dalarn perencaaan diet dengan nutrisi adekuat unruk kebutuhan
metabolik dan diet.

i. Konsul dengan tim medis untuk jadwal pengobatan 1-2 jam sebelum/setelah makan.
Rasional: Membantu menurunkan insiden mual dan muntah karena efek samping obat.
j. Awasi pemeriksaan laboratorium. (BUN, protein serum, dan albumin).
Rasional: Nilai rendah menunjukkan malnutrisi dan perubahan program terapi.
k. Berikan antipiretik tepat.
Rasional: Demam meningkatkan kebutuhan metabolik dan konsurnsi kalori.

Thoracentesis
Thoracentesis is a procedure to remove fluid from the space between the lining of the outside of
the lungs (pleura) and the wall of the chest.

How the Test is Performed
A small area of skin on your back is cleaned. Numbing medicine (local anesthetic) is injected in
this area.
A needle is placed through the skin and muscles of the chest wall into the space around the lungs,
called the pleural space. Fluid is collected and may be sent to a laboratory for testing (pleural
fluid analysis).
How to Prepare for the Test
No special preparation is needed before the test. A chest x-ray will be performed before and after
the test.

Do not cough, breathe deeply, or move during the test to avoid injury to the lung.
How the Test Will Feel
You will sit on a bed or on the edge of a chair or bed. Your head and arms will rest on a table.
The skin around the procedure site is cleaned and the area is draped. A local numbing medicine
(anesthetic) is injected into the skin. The thoracentesis needle is inserted above the rib into the
pleural space.
You will feel a stinging sensation when the local anesthetic is injected. You may feel pain or
pressure when the needle is inserted into the pleural space.
Tell your health care provider if you feel shortness of breath or chest pain.
Why the Test is Performed
Normally, very little fluid is in the pleural space. A buildup of too much fluid between the layers
of the pleura is called a pleural effusion.
The test is performed to determine the cause of the extra fluid, or to relieve symptoms from the
fluid buildup.
The test may be also performed for the following conditions:
 Asbestos-related pleural effusion
 Collagen vascular disease
 Drug reactions
 Hemothorax
 Pancreatitis

 Pneumonia
 Pulmonary embolism
 Pulmonary veno-occlusive disease
 Thyroid disease
Normal Results
Normally the pleural cavity contains only a very small amount of fluid.
What Abnormal Results Mean
Testing the fluid will help your health care provider determine the cause of pleural effusion.
Possible causes include:
 Cancer

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Cirrhosis
Heart failure

Infection
Inflammation
Malnutrition
Kidney disease

If your health care provider suspects that you have an infection, a culture of the fluid may be
done to test for bacteria.
Risks
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Bleeding
Fluid buildup in the lungs
Infection
Pneumothorax
Pulmonary edema

Respiratory distress

Considerations
A chest x-ray is often done after the procedure to detect possible complications.
Alternative Names
Pleural fluid aspiration; Pleural tap
References
Blok BK. Thoracentesis. In: Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 5th
ed. Philadelphia, Pa: Saunders Elsevier; 2009:chap 9.
Celli BR. Diseases of the diaphragm, chest wall, pleura, and mediastinum. In: Goldman L, Ausiello D, eds.
Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 100.
Update Date: 9/15/2010
Updated by: David C. Dugdale, III, MD, Professor of Medicine, Division of General Medicine, Department
of Medicine, University of Washington School of Medicine; Denis Hadjiliadis, MD, Assistant Professor of
Medicine, Division of Pulmonary, Allergy and Critical Care, University of Pennsylvania, Philadelphia, PA.
Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

Bronchoscopy
Bronchoscopy is a test to view the airways and diagnose lung disease. It may also be used during
the treatment of some lung conditions.
How the Test is Performed
A bronchoscope is a device used to see the inside of the lungs. It can be flexible or rigid. Usually,
a flexible bronchoscope is used. The flexible bronchoscope is a tube less than 1/2 inch wide and
about 2 feet long.

The scope is passed through your mouth or nose, through your windpipe (trachea), and then into
your lungs. Going through the nose is a good way to look at the upper airways. The mouth
method allows the doctor to use a larger bronchoscope.
A rigid bronchoscope requires general anesthesia. You will be asleep.
If a flexible bronchoscope is used, you will be awake. The doctor will spray a numbing drug
(anesthetic) in your mouth and throat. This will cause coughing at first, which will stop as the
anesthetic begins to work. When the area feels thick, it is numb enough. You may get
medications through a vein (intravenously) to help you relax.
If the bronchoscopy is done through the nose, numbing jelly will be placed into one nostril.
Once you are numb, the tube will be inserted into the lungs. The doctor may send saline solution
through the tube. This washes the lungs and allows the doctor to collect samples of lung cells,
fluids, and other materials inside the air sacs. This part of the procedure is called a lavage.
Sometimes, tiny brushes, needles, or forceps may be passed through the bronchoscope and used
to take tissue samples (biopsies) from your lungs. The pieces of lung material that are removed
are small. The doctor can also place a stent in the airway or view the lungs with ultrasound
during a bronchoscopy.
How to Prepare for the Test
Do not eat or drink anything 6 - 12 hours before the test. Your doctor may also want you to avoid
any aspirin, ibuprofen, or other blood-thinning drugs before the procedure.
You may be sleepy after the test, so you should arrange for transportation to and from the
hospital.
Many people want to rest the following day, so make arrangements for work, child care, or other
obligations. Usually, the test is done as an outpatient procedure, and you will go home the same
day. Some patients may need to stay overnight in the hospital.
How the Test Will Feel
Local anesthesia is used to relax the throat muscles. Until the anesthetic begins to work, you may
feel fluid running down the back of your throat and have the need to cough or gag.
Once the anesthetic takes effect, you may have sensations of pressure or mild tugging as the tube
moves through the windpipe (trachea). Although many patients feel like they might suffocate
when the tube is in the throat, there is NO risk of suffocation. If you cough during the test, you
will get more anesthetic.
When the anesthetic wears off, your throat may be scratchy for several days. After the test, the
cough reflex will return in 1 - 2 hours. You will not be allowed to eat or drink until your cough
reflex returns.
Why the Test is Performed
You may have a bronchoscopy to help your doctor diagnose lung problems. Your doctor will be
able to inspect the airways or take a biopsy sample.
Common reasons to perform a bronchoscopy are:
 Lung growth, lymph node, atelectasis, or other changes seen on an x-ray or other imaging
test
 Suspected interstitial lung disease
 Coughing up blood (hemoptysis)
 Possible foreign object in the airway

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Cough that has lasted more than 3 months without any other explanation
Infections in the lungs and bronchi
Inhaled toxic gas or chemical

You may also have a bronchoscopy to treat a lung or airway problem, such as:
 Remove fluid or mucus plugs from your airways
 Remove a foreign object from your airways
 Widen (dilate) an airway that is blocked or narrowed
 Drain an abscess
 Treat cancer using a number of different techniques
 Wash out an airway (therapeutic lavage)
Normal Results
Normal cells and secretions are found. No foreign substances or blockages are seen.
Normal value ranges may vary slightly among different laboratories. Talk to your doctor about
the meaning of your specific test results.
What Abnormal Results Mean
 Granulomas
 Infections from bacteria, viruses, fungi, parasites, or tuberculosis
 Aspiration pneumonia
 CMV pneumonia
 Chronic pulmonary coccidioidomycosis
 Cryptococcosis
 Chronic pulmonary histoplasmosis
 Pneumonia with lung abscess
 Pulmonary actinomycosis
 Pulmonary aspergilloma (mycetoma)
 Pulmonary aspergillosis (invasive type)
 Pulmonary histiocytosis X (eosinophilic granuloma)
 Pulmonary nocardiosis
 Pulmonary tuberculosis
 Inflammation of the lungs related to allergy-type reactions (hypersensitivity pneumonitis)
 Interstitial lung disease
 Lung cancer or cancer in the area between the lungs
 Narrowing (stenosis) of the trachea or bronchi
 Rheumatoid lung disease
 Sarcoidosis
 Vasculitis
Risks
The main risks from bronchoscopy are:
 Bleeding from biopsy sites
 Infection

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There is also a small risk of:
Arrhythmias
Breathing difficulties
Fever
Heart attack
Low blood oxygen
Pneumothorax
Sore throat

In the rare instances when general anesthesia is used, there is some risk for:
Muscle pain
Change in blood pressure
Slower heart rate
Nausea
Vomiting
There is a small risk for:
Heart attack
When a biopsy is taken, there is a risk of severe bleeding (hemorrhage). Some bleeding is
common. The technician or nurse will monitor the amount of bleeding.
There is a significant risk of choking if anything (including water) is swallowed before the
numbing medicine wears off.
Considerations
After the procedure, your gag reflex will return. However, until it does, do not eat or drink
anything.
To test if the gag reflex has returned, place a spoon on the back of your tongue for a few seconds
with light pressure. If you don't gag, wait 15 minutes and try it again. Make sure that you don't
use any small or sharp objects to test this reflex.
Alternative Names
Fiberoptic bronchoscopy
References
Kraft M. Approach to the patient with respiratory disease. In: Goldman L, Ausiello D, eds. Cecil
Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 83.
Reynolds HY. Respiratory structure and function: mechanisms and testing. In: Goldman L,
Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 85.
Prakash UBS. Bronchoscopy. In: Mason RJ, Murray J, VC Broaddus, Nadel J, eds. Textbook of
Respiratory Medicine. 4th ed. Philadelphia, Pa: Saunders Elsevier; 2005:chap 22.

Update Date: 4/27/2010
Updated by: Allen J. Blaivas, DO, Clinical Assistant Professor of Medicine UMDNJ-NJMS,
Attending Physician in the Division of Pulmonary, Critical Care, and Sleep Medicine,
Department of Veteran Affairs, VA New Jersey Health Care System, East Orange, NJ. Review
provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director,
A.D.A.M., Inc.