NURSING INTERVENTION DIAGNOSE 1
PURPOSE AND CRITERIA
RESULTS
After being given 5x 24 hours
askep, it is hoped that the client's
airway clearance is effective with
the result criteria:
NOC Label >> Respiratory
status: airway patency
 Respiratory frequency within
normal limits (16-20x /
minutes)
 Respiratory normal rhythm
 Normal breathing depth
 Clients are able to
secrete secretions effectively
 No mucous accumulation
INTERVENTION
NIC Labels >> Respiratory monitoring
1. Monitor rate, rhythm, depth, and effort
respiration
2. Pay attention to chest movements, observe
symmetry, use of accessory muscles,
supraclavicular and intercostal muscle
retractions
3. Monitor additional breath sounds
4. Monitor breath patterns: bradypnea,
tachypnea, hyperventilation, kussmaul breath,
cheyne-stokes breath, apnea, biot's breath and
ataxic pattern
NIC Labels >> Airway Management
5. Auscultate additional breath sounds; ronchi,
wheezing.
6. Provide a comfortable position to reduce
dyspnea.
7. Clean the secretions from the mouth and
RATIONAL
1. Know the level of disturbance that occurs and help in
determining the intervention to be provided.
2. shows the severity of the respiratory disorder that occurs
and determines the intervention to be administered
3. additional breath sounds can be an indicator of airway
patency disorders that will certainly affect the adequacy of
air exchange.
4. knowing the airway problems experienced and the
effectiveness of the client's breathing patterns to meet the
body's oxygen needs.
5. The presence of ronchi sounds indicates a buildup
of excessive secretions or secretions in the airway.
6. position to maximize lung expansion and decrease
respiratory effort. Maximal ventilation opens the area of
atelectasis and increases secretion movement to the large
airway for removal.
7. Preventing obstruction or aspiration. Sucking may
 trachea; do the appropriate sucking.
8. Encourage adequate fluid intake.
9. Teach effective cough
10. Collaboration of oxygen delivery
11. Collaboration of broncodilator according to
indication.
NIC Labels >> Airway suctioning
12. Decide when oral and / or suction trachea are
needed
13. Auscultation of breath before and after suction
14. Inform the family about the suction action
15. Use universal precaution, gloves, goggles,
mask as needed
be necessary if a client can not afford to remove his own
secret.
8. Optimizes fluid balance and helps to dilute the
secretions so they are easily removed
9. Chest physiotherapy / back massage can help drop
the existing secret in the air.
10. Relieve lung work to meet the needs of oxygen
and meet the needs of oxygen in the body.
11. The broncodilator increases the size of the
tracheobronchial branching lumen thus reducing the
resistance to airflow.
12. the timing of the proper suction action helps the
patient's airway
13. Recognizing additional breath sounds and airway
effectiveness to meet O2 patients
14. provide understanding to the family about the
indication of why the act of suction is done
15. to protect health workers and patients from the
spread of infection and provide patient safety
 NURSING IMPLEMENTATION AND EVALUATION

NO Nursing HOUR IMPLEMENTATION INITIALS EVALUATION

Diagnose
1. Ineffective 09.0 rs NIC Labels >> Respiratory monitoring S: The patient's family says the line is
airway 1. Monitoring rate, rhythm, depth, and effort still there and the patient can not
clearance is respiration get it out.
associated with 2. Monitoring chest movements, observe
excess mucus symmetry, use of accessory muscles, O:
and restrained supraclavicular and intercostal muscle  the patient appears weak
secretions retractions  it appears that secretaries
3. Monitoring additional breath sounds can not be actively removed
4. Monitoring breathing patterns: bradypnea,  there appears to be an
tachypnea, hyperventilation, Kussmaul excessive accumulation of
breath, breath Cheyne-Stokes, apnea, mucus
airway biot's and ataxic patterns  TTV
NIC Labels >> Airway Management TD: 120/80 mmHg
P: 75x.min
5. Consultation of additional breath
R: 24x / min
sounds; ronchi, wheezing.
Q: 36 0 C
6. Giving comfortable position to reduce
SPO2: 98% using 2 lpm
dyspnea.
nasal cannula
7. Given secretions from the mouth and
trachea; do the appropriate sucking.
A: the problem is not resolved
8. Advocacy adequate fluid intake.
9. Teaching effective cough
10. Colaboration in giving oxygen
11. Colaboration in giving broncodilator as
indicated.
NIC Labels >> Airway suctioning
12. Verdict when oral and / or suction
trachea is needed
13. Consultation breath before and after
suction
14. Inform families about suction actions
15. Using universal precaution, gloves,
goggle, mask as needed .
P:
1. Monitor rate, rhythm, depth, and
effort respiration
2. Monitor chest movements,
observe symmetry, use of
accessory muscles,
supraclavicular and intercostal
muscle retractions
3. Monitoring additional breath
sounds
4. Monitoring breathing patterns:
bradypnea, tachypnea,
hyperventilation, Kussmaul
breath, breath Cheyne-Stokes,
apnea, airway biot's and ataxic
patterns
5. Consultation of additional breath
sounds;ronchi, wheezing.
6. Givingcomfortable position to
reduce dyspnea.
7. Givingsecretions from the mouth
and trachea;do the appropriate
sucking.
8. Teaching effective cough
9. Colaboration in giving oxygen
10. Colaboration in giving
broncodilator as indicated.
11. Collaborate on suction
actions.
 NURSING INTERVENTION DIAGNOSE 2

PURPOSE AND CRITERIA

INTERVENTION RATIONAL
RESULTS
The client is able to demonstrate 1. Monitor frequency, heart rhythm, and TTV 1. To know the heartbeat koodinasi and mengtahui whether
increased activity tolerance after there is a disturbance in heart rhythm
2 x 24 hour nursing action with
outcome criteria: 2. Limit activity and advise rest 2. To overhaul the pump or excessive heart work
-TTV within normal limits
 TD: 120/80 mmHg
 Nadi: 60 - 100 x / min 3. Encourage clients to avoid abdominal pressure
3. To prevent the heart beat faster
 RR: 16 - 24 x / min (straining) during defecation
 Temperature: 36-37 oC
4. To help patients meet ADL needs
 acral warm 4. Helps ADL fulfillment
 reported no chest pain /
controlled chest pain
 NURSING IMPLEMENTATION AND EVALUATION

NO IMPLEMENTATION - EVALUATION
RESPONSE
2 1. Monitor frequency, heart S: The patient's child says "the mother is able to move
rhythm, and TTV in bed and can already tilt left and mriring right"
O:
2. Encourage clients to restrict - Clients look fresher
activities and perform activities - Client bedrest
according to ability - Installed O2 2 L / m
- TTV
TD = 120/80 mmHg
3. Encourage clients to avoid P = 74 x / min
abdominal pressure (straining) R = 24 x / min
during defecation T = 36 o C
- TD 148/90 mmHg
4. Helping clients meet ADL - Nadi 88 x / min
needs A: Partially resolved problem
P: Continue intervention
1. Monitor frequency, heart rhythm, and TTV
2. Limit activity and advise rest
3. Encourage clients to avoid abdominal pressure
(straining) during defecation
4. Helps ADL fulfillment
 DEVELOPMENT NOTES
NO DAY / DIAGNOSIS HOUR EVALUATION INITIALS
DATE
1 5/07/2018 Ineffective S:
airway The patient's family says there are
clearance is still secretions and the patient is
associated still unable to remove the
with restrained secretions.
secretions,
excess mucus O:
 the patient appears weak
 it appears that secretaries
can not be actively
removed
 there appears to be an
excessive accumulation of
mucus
 TTV
TD: 130/80 mmHg
P: 89x.min
R: 20x / min
Q: 36 0 C
 SPO2: 99% using 2 lpm
nasal cannula

A: nursing issues have not been

resolved
P:
1. Monitor rate, rhythm, depth,
and effort respiration
2. Monitor chest movements,
observe symmetry, use of
accessory muscles,
supraclavicular and intercostal
muscle retractions
3. Monitoring additional breath
sounds
4. Monitoring breathing patterns:
 bradypnea, tachypnea,
hyperventilation, Kussmaul
breath, breath Cheyne-Stokes,
apnea, airway biot's and ataxic
patterns
5. Consultation of additional
breath sounds;ronchi,
wheezing.
6. Givingcomfortable position to
reduce dyspnea.
7. Givingsecretions from the
mouth and trachea;do the
appropriate sucking.
8. Teaching effective cough
9. Colaboration in giving oxygen
10. Colaboration in giving
broncodilator as indicated.
11. Collaborate on suction actions.
2 05-07-2018 Intolerance S: The patient's child says "the
08:00 to activity is
mother is able to move in bed
14:00 hours associated
with an and can already tilt left and
imbalance of mriring right"
oxygen supply
O:
- Clients look fresher
- Client bedrest
- Installed O2 2 L / m
- TTV
TD = 120/80 mmHg
P = 76 x / min
R = 24 x / min
T = 36 o C
- TD 148/90 mmHg
- Nadi 88 x / min
A: Partially resolved problem
P: Continue intervention
1. Monitor frequency, heart
rhythm, and TTV
2. Limit activity and advise
rest
3. Encourage clients to avoid
abdominal pressure
(straining) during
defecation
4. Helps ADL fulfillment