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7/30/2019 laporan HECTING

1/12

N

o.

Diagnosa NOC NIC

1. Ineffective airway clearence related to

tracheobronchial obstruction as

manifested by tissue oedema and stridor

sound

Definitions :

Inability to secretion or obstruction from

the respiratory tract to maintain airway

patency

1. Respiratory

Status : Airway

Patency

Common expected

Outcome :

Patient secretion

are mobilized and

airway is free of

execessivesecretion, as

evidenced by clear

lung sounds,

eupnea and

inability to

effectively cough

up secretion after

treatment and deep

breath

1. Cough

enhancement:

airway

2. Management :

Airway

Suctioning

0ngoing Assesment :

o Asses airway for

patency

o Auscultate lungs

for present of

adventitious breath

sound

o Asses respiration :

note quality, rate,

rhytm, depth,

flaring of nostril,

dyspneu, use of

accesory muscles

and position for

breathing

o Asses cough for

effectiveness and

productivity

Therapeutic

Interventions

o Assist the patient


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strategies

2. Ineffective Breathing Pattern related to

tracheobronchial obstruction as

manifested by stridor sounds

Definitions

Inspiration or expiration that does not

provide adequate ventilation

1. Respiratory

Status :

Ventilation ;

vital signs

status

Common

expected outcome

:

Patients breathing

pattern iseffectively

maintained as

evidenced by

eupnea, normal

skin color and

minimal or no

complains of

dyspnea

1. Airway

Management ;

Respiratory

Monitoring

0ngoing Assesment :

o Asses respiratory

rate, rhytm, depth

o Asses for the

quality, duration,

intensity, and

distress assosiated

with dispnea

o Asses nutritional

status (e.g weight,

albumin and

electrolyte level)

o Monitoring

breathing pattern

o Observ for

excessive use

acessory muscles.

o Monitor for

diagframatic

muscle fatigue or

weakness

Therapeutic

Intervention :


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o Position the

patient with proper

body alignment for

optimal breathing

pattern

o Encourage the

patient to clear

his / her own

secretion with

effective cough

o Provide relaxation

training as

appropriate

o Use pain

management as

appropriate

Education /

Continuity of Care

o Explain use of

oxygen therapy,

including the type

and use of

equipment and

why its

maintainance is

important

3. Impaired Gas Exchange related to altered

blood flow as manifested by restlessness

Definition :

1. Respiratory

Status : Gas

Exchange

1.Respiratory

Monitoring;

Oxygen


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Excess or deficient in oxygention and or

carbondioxide elimination alveolar

capilary membran

Common expected

Outcome :

Patient maintanance

optimal gas exchange

as manifested by

arterial blood gases

(ABGs) witihn the

patient usual range,

alert responsive

mentation or no

further reduction and

mental status, and no

sign of respiratory

distress

Therapy ; Airway

Management

Ongoing Assesment

o Asses respiration :

note quality, rate,

rhytm, depth and

breathing effort

o Asses lung sound,

noting area of

decrease

ventilation and the

present of

adventitious

sounds

o Asses for

tachycardia,

restlessness,

diaphoresis,

headache, visual

disturbance and

confusion

o Asses skin color

for development

cyanosis

o Monitor effects of

position change on

oxygenation

(ABGs, SVO2 and


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pulse oximetry)

Therapeutic

Intervention

o

4. Ineffective peripheral tissue perfusion

related to blockage of microcirculation as

manifested by brain injury in chest, face,

and hands area

Definitions :

Decrease in oxygen resulting in failure to

nourish the tissues at capilarry refill

1.Circulation

Status : tissue

perfussion ;

peripheral

Common expected

Outcome :

Patient maintain

normal tissue

perfussion to

extremities, as

evidenced by palpable

pulses in all

extremities, andnormal sensation in

extremity

1. Circulatory

Care ; Vital Sign

monitoring

Ongoing assesment :

o Asses for signs of

decrease

peripheral tissue

perfusion like cold

extremity.

o Monitor vital

signs: BP,HR, and

RR for abrupt

change

o Asses color and

temperature

extremities

o Check for pain ,

numbness,

swelling of

extremities

Therapeutic

Intervention

o Maintain good

alignment of


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extremity

o Apply sequential

compression

device on non

burned extremities

o Perform passive

range of motion

Prepare for and assist

with fasciotomy and

escharotomy

5 Impaired skin integrity related to

mechanical force (friction, shear,

pressure)

1. Tissue Integrity :

Skin and Mucous

membrane

2. Wound healing :

Primary intentions

3. Wound healing :

secondary intentions

Common Expected

Outcome:

Condition in impaired

tissue improves as

evidenced by

decreased redness,

swelling and pain

1. Wound Care;

Infection Protection;

Teaching:

Prescribed

Medication

Ongoing Assesment

a.Determine the

etiology of tissue

damage.b. Assess the

patients level of

discomfortc.Identify signs of

itching and

scratching

d. Assess thepatients nutritional

status, including

weight, weightloss, and serum

albumin level if

orderede. assess for

environmental

moisture (wound


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drainage, excessive

perspiration, highhumidity)

f. assess skin on

admission and

daily for increasingnumber of risk

factorsg. assess the

condition of

surrounding tissue.

Therapeutic

Intervention

a.Cleanse withnormal saline or a

non toxic cleanser,

as appropriateb. Maintain

sterile dressing

technique during

wound care.c.Initiate pressure-

relieving devices as

needed andimprove circulation

to painful area

d. Administeredantibiotic as

ordered

Education/

Continuity of Care

a.Teach patient or

caregiver about

cause of tissueintegrity

impairment

b. Instruct thepatient or caregiver

in proper care of

wound

c.Teach patient or


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caregiver about

sign and symptomsof infection and

when to notify the

physician or nurse

d. Teach thepatient or caregiver

pain controlmeasures

6. Risk for infection related to inadequate

primary defences: broken skin as

manifested by open punctum scissum

Definitions : at increased for being

invaded by pathogenic organism

Imune status;

knowledge: infection

control

1. Patient

remains free

of local orsystem

infection, asevidenced by

absence of

copious, foul-

smellingwound

exudates.

2. patientmaintains

normal body

temperature3. infection is

recognize

early to allow

for prompttreatment

Infection control;

infection protection

Ongoing assesment

1. assess punctun

scissum for

drainage,color of tissue

and odor2. assess

nutritional

status

3. monitorsign ofinfection:

temperature,

redness,increase pain,

swelling,

purullendrainage

Therapeutic

intervention

1. maintain orteach a sepsis

for dressing

changes and

wound care2. provide wound

care asprescribed

3. obtain wound

culture if

available4. monitor WBC


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count

Education or

continuity of care

1. teach thepatient and

caregiver the

sign and

symptomsinfection and

when to report

this to thephysician and

nurse

2. administerantibiotic as

prescribed

N

o

Nursing Diagnosa NOC NIC

7. Acute pain related to pain resulting

from trauma as manifest by patient

report pain

Comfort level;

medication response;

pain control

Common expected

outcome: patient

verbalize adequate

relief of pain or

ability to cope withincompletely relieved

pain

Analgesic

administration;

conscious sedation;

pain management;

pain controlled

analgesia assistance

Ongoing assessment

a. asses pain

characteristics :

quality, severity,

locatition, onset,

duration,

precipitating or


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relieving factors

b. observe or

monitor signs and

symptoms

associated withpain, blood

pressure, HR,

temperature,

colour and

moisture of skin,

restlessness and

ability to focus.

c. Asses to what

degree cultural,environtmental,

interpersonal and

intraphysics

factors may

contribute to pain

or pain relief

d. Monitor the

patient for

changes in generalcondition that may

herald need for

change in pain

relief methods.

e. Numbness,

tingling in

extremities.

Therapeuticintervention

a. anticipate need for

pain relief

b. eliminate

additional stressor


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or resources of

discomfort

whenever possible

c. Give analgesic as

ordered

d. Determine the

appropriate pain

relief method:

pharmacological

and non

pharmacological.

Education/continuity

of care

a.instruct the patient

to report pain

b. instruct the patient

to evaluate

effectiveness of

measure used

c. teach the patient

effective timing of

medication dose in

relation to potentially

uncomfortable

activities and

prevention of peak

pain period

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