The future starts today, www.umy.ac.

id

not
Basic Human tomorrow.
Need : Oxygenation
Resti Yulianti Sutrisno, M.Kep., Ns., Sp.Kep.MB
PSIK FKIK UMY
System for Oxygenation

• The cardiac and respiratory systems supply the

oxygen demands of the body.
• The Respiratory system → Blood is oxygenated
through the mechanisms of ventilation, perfusion,
and transport of respiratory gases.
• The cardiovascular system → provides the transport
mechanisms to distribute oxygen to cells and tissues
of the body.
• Neural and chemical regulators control the rate and depth of
respiration in response to changing tissue oxygen demands.
There are three steps in the process of oxygenation

❑ Ventilation : The process of moving gases into and out

of the lungs (from the atmosphere to the alveoli)
Inspiration is an active process, stimulated by chemical receptors
in the aorta. Expiration is a passive process that depends on the
elastic recoil properties of the lungs
❑ Difussion : the process for the exchange of respiratory
gases in the alveoli and the capillaries; and also
capillaries and cells
Diffusion of respiratory gases occurs at the alveolar capillary
membrane
❑ Perfussion / Transportation : The ability of the
cardiovascular system to pump oxygenated blood to
the tissues and return deoxygenated blood to the
lungs
❑ Respiration is the exchange of oxygen and carbon
dioxide during cellular metabolism.
Factors Affecting Oxygenation

Four factors influence adequacy of circulation, ventilation,

perfusion, and transport of respiratory gases to the tissues:
(1) physiological,
(2) developmental,
(3) lifestyle, and
(4) environmental
 Physiological Factors of Oxygenation

Decreased Oxygen-Carrying Capacity. Hypovolemia

Hemoglobin carries the majority of oxygen to ❑ Conditions such as shock and
severe dehydration cause
tissues
extracellular fluid loss and
Decrease the oxygen-carrying capacity of blood by reducing
reduced circulating blood
the amount of available hemoglobin to transport oxygen)
volume, or hypovolemia.
• Anemia ❑ Decreased circulating blood
(i.e., a lower-than-normal hemoglobin level) is a result volume results in hypoxia to
of decreased hemoglobin production, increased red body tissues.
blood cell destruction, and/ or blood loss. ❑ With significant fluid loss, the
• Toxic Inhalant body tries to adapt by
Carbon monoxide (CO) is the most common toxic peripheral vasoconstriction
inhalant decreasing the oxygen-carrying capacity of and increasing the heart rate
blood. In CO toxicity hemoglobin strongly binds with to increase the volume of blood
CO, CO does not easily dissociate from hemoglobin, returned to the heart, thus
making hemoglobin unavailable for oxygen transport. increasing the cardiac output.
 Physiological Factors of Oxygenation

Decreased Inspired Oxygen Concentration

With the decline of the concentration of inspired oxygen, the oxygen-carrying
capacity of the blood decreases. Decreases in the fraction of inspired oxygen
concentration (FiO2) are caused by
• Upper or lower airway obstruction, which limits delivery of inspired
oxygen to alveoli;
• Decreased environmental oxygen at high altitudes
❑ Surah Al-An’am [6]: 125, Allah SWT berfirman”: “Siapa saja yang dikehendaki Allah
menunjukinya, niscaya Dia melapangkan dadanya untuk memeluk (agama) Islam. Dan
Siapa yang dikehendaki Allah kesesatannya, niscaya Dia menjadikan dadanya sesak lagi
sempit, seolah-olah ia sedang mendaki ke langit. Begitulah Allah menimpakan siksa
kepada orang-orang yang tidak beriman.”
❑ Setiap bertambah ketinggian naik ke udara, maka akan bertambah sesak
napasnya karena berkurangnya tekanan udara. Sehingga berkurang jumlah
oksigen yang dihirup paru-paru.
• Hypoventilation (occurs in drug overdoses).
 Physiological Factors of Oxygenation

Increased Metabolic Rate

❑ Increased metabolic activity increases oxygen demand.
❑ An increased metabolic rate is normal in pregnancy, wound healing, and exercise
because the body is using energy or building tissue.
❑ Fever increases the need of tissues for oxygen; as a result carbon dioxide
production increases. When fever persists, the metabolic rate remains high, and
the body begins to break down protein stores.
 Physiological Factors of Oxygenation
Conditions Affecting Chest Wall
Movement
❑ Pregnancy
❑ Obesity
❑ Musculoskeletal Abnormalities (abnormal
structural configurations, trauma, muscular diseases, and
diseases of the central nervous system)
❑ Trauma. (Flail chest is a condition in which multiple rib
fractures cause instability in part of the chest wall)
❑ Neuromuscular Diseases myasthenia gravis,
Guillain-Barré syndrome, and poliomyelitis.
❑ Central Nervous System Alterations.
Cervical trauma at C3 to C5 usually results in paralysis of
the phrenic nerve.
❑ Influences of Chronic Disease. Changes in
the anteroposterior diameter of the chest wall (barrel
chest) occur because of overuse of accessory muscles and
air trapping in emphysema.
Alterations in Cardiac
Functioning
❑Disturbances in Conduction
Dysrhythmias occur as a primary conduction disturbance
such as in response to ischemia; valvular abnormality;
anxiety; drug toxicity; caffeine, alcohol, or tobacco use; or
as a complication of acid-base or electrolyte imbalance
❑Altered Cardiac Output.
Left-Sided Heart Failure. Right-Sided Heart Failure.
❑Impaired Valvular Function
Valvular heart disease is an acquired or congenital disorder of a
cardiac valve that causes either hardening (stenosis) or
impaired closure (regurgitation) of the valves. When stenosis
occurs, the flow of blood through the valves is obstructed.
❑Myocardial Ischemia.
Physiological Factors of Oxygenation - Alterations in Respiratory Functioning

Hiperventilasi Hipoventilasi Hipoksia

 Kondisi ventilasi  Terjadi ketika ventilasi  Oksigenasi jaringan
berlebihan yang alveolar tidak cukup yang tidak adekuat
diperlukan untuk untuk memenuhi pada level seluler
membuang CO2 yang kebutuhan oksigen  Penyebab: penurunan
diproduksi oleh atau membuang kadar HB,
metabolisme seluler kecukupan CO2 Berkurangnya
 Kecemasan, infeksi,  Contoh kasus kosentrasi oksigen,
obat-obatan, atelektasis, kolaps Gangguan ventilasi
ketidakseimbangan alveoli, PPOK (trauma dada),
asam basa akan  Hanya sedikit paru perfusi jaringan buruk
menginduksi yang berventilasi (syok), penurunan
hiperventilasi difusi (pneumonia)
 Developmental Factors of Oxygenation
Bayi dan Anak-Anak
 Rentan infeksi pernapasan
 Terpapar asap rokok
Usia Sekolah dan Remaja
 Rentan infeksi pernapasan
 Terpapar asap rokok
 Mulai merokok
Dewasa Muda dan
Pertengahan
 Diet tidak sehat, stress,
kurang olah raga, merokok,
alkohol
Lansia
 Sistem pernapasan dan
jantung mengalami
perubahan karena penuaan
 Kalsifikasi katup jantung,
nodus SA, tulang rawan iga,
plak aterosklerosis
 Alveoli membesar
sehingga mengurangi
area difusi
 Jumlah silia menurun
sehingga penurunan
efektifitas batuk
 Lifestyle Factors of Oxygenation
Merokok
 Nikotin menyebabkan
vasokontriksi perifer dan
pembuluh darah koroner dan
meningkatkan tekanan darah,
serta menurunkan aliran darah
ke perifer
 Faktor resiko PPOK, Kanker paru
Alkohol
 Menekan pusat pernapasan
 Menurunkan frekuensi dan
kedalaman pernapasan serta
oksigen yang dihirup
Olah Raga
 Meningkatkan aktivitas metabolisme
dan kebutuhan oksigen
 Orang yang olah raga rutin 30-60
menit setiap hari memiliki frekuensi
nadi dan tekanan darah lebih rendah,
peningkatan aliran darah, mengambil
oksigen yang lbh banyak utk kerja otot
Stress
 Stress dan ansietas yang berlanjut
meningkatkan laju metabolisme tubuh
dan kebuthan oksigen
 Environmental Factors of Oxygenation -

 Polutan asbes, debu, serat

 Asbestosis : penyakit paru yang terjadi akibat
terpapar asbes
 Pasien terpapar asbes beresiko kankerparu
 Paparan debu beresikomenyebabkan kekambuhan
asma karena faktor alergi
 Nursing Process - Assessment
❑Dyspnea
• Dyspnea is a clinical sign of hypoxia.
• It is the subjective sensation of difficult or uncomfortable breathing.
• Dyspnea is shortness of breath usually associated with exercise or
excitement, but in some patients it is present without any relation to
activity or exercise.
❑Cough
❑ Hemoptysis
(bloody sputum) is present, determine if it is associated with coughing and
bleeding from the upper respirator
❑ Wheezing.
Wheezing is a high-pitched musical sound caused by high-velocity
movement of air through a narrowed airway.
❑Pain
• The presence of chest pain requires an immediate thorough evaluation,
including location, duration, radiation, and frequency.
• Cardiac pain → Chest pain in men is most often on the left side of the
chest and radiates to the left arm.
• Pleuritic chest pain is peripheral and radiates to the scapular regions.
Inspiratory maneuvers such as coughing, yawning, and sighing worsen
pleuritic chest pain
• Musculoskeletal pain is often present following exercise, rib trauma, and
prolonged coughing episodes. Inspiration worsens this pain, and patients
often confuse it with pleuritic chest pain.
❑ Nursing History.
• The nursing history for respiratory function includes the presence of a cough, shortness
of breath, dyspnea, wheezing, pain, environmental exposures, frequency of respiratory
tract infections, pulmonary risk factors, past respiratory problems, current medication
use, and smoking history or secondhand smoke exposure.
• The nursing history for cardiac function includes pain and characteristics of pain, fatigue,
peripheral circulation, cardiac risk factors, and the presence of past or concurrent cardiac
conditions. Ask specific questions related to cardiopulmonary disease
❑ Environmental or Geographical Exposures.
❑ Smoking.
IB = packages per day × years smoked
❑ Respiratory Infections.
Obtain information about the patient’s frequency and duration of respiratory tract
infections
❑ Allergies.
Inquire about your patient’s exposure to airborne allergens (e.g., pet dander or mold). The
allergic response is often watery eyes, sneezing, runny nose, or respiratory symptoms such
as cough or wheezing.
❑ Health Risks.
Determine familial risk factors such as a family history of lung cancer or cardiovascular
disease. infectious diseases, particularly TB.
❑ Medications.
Another component of the nursing history describes medications that a patient is using.
These include prescribed medications, over-the-counter medications, folk medicine,
herbal medicines, alternative therapies, and illicit drugs and substances
 Nursing Process - Assessment
Nature of the Cardiopulmonary Problem
❑ What types of breathing problems are you having?
❑ Describe the problem that you’re having with your heart.
❑ Does the problem (e.g., chest pain, rapid heart rate) occur
at a specific time of the day, during or after exercise, or all
the time?
Signs and Symptoms
❑ How has your breathing pattern changed?
❑ Do you have sputum with coughing? Is this different?
❑ Is your sputum a different color?
❑ Are you having any chest pain? Does the pain occur with
breathing?
Onset and Duration
❑ If you are having chest pain, what causes the pain and how
long does it last? Is this a different type of pain?
❑ When did you notice your sputum change in color and
amount?
❑ When did your coughing increase? How does this differ
from your usual pattern of coughing?
Severity
❑ On a scale of 0 to 10, with 10 being the most severe, rate
your shortness of breath.
❑ What helps relieve your shortness of breath?
❑ On a scale of 0 to 10, with 0 being no pain and 10 the
most severe pain, rate your chest pain. Is the severity of
your pain different today?
❑ What do you do for this pain?
Predisposing Factors
❑ Have you been exposed to a cold or flu?
❑ Are you taking your prescribed medications?
❑ Do you smoke? Have you been exposed to secondhand
smoke?
❑ Have you been doing any unusual exercises?
Effect of Symptoms on Patient
❑ Do these symptoms affect your daily activities? If so how?
❑ What impact do
 Physical Examination - Inspection

❑ Using inspection techniques, perform a head-to-toe

❑ Observation of the patient for skin and mucous membrane color,
general appearance, level of consciousness, adequacy of systemic
circulation
❑ Observe the patient’s breathing pattern and assess for
paradoxical breathing (the chest wall contracts during inspiration
and expands during exhalation) or asynchronous breathing.
• At rest the normal adult rate is 16 to 24 regular breaths/min.
• Bradypnea is less than 12 breaths/min
• Tachypnea is greater than 24 breaths/min.
• In some conditions, such as metabolic acidosis, the acidic pH stimulates
an increase in both rate and depth of respirations (Kussmaul
respiration).
• Apnea is the absence of respirations for a period of time. The apnea
periods can last 15 to 60 seconds Cheyne-Stokes respiration occurs when
there is decreased blood flow or injury to the brainstem.
 Physical Examination - Inspection

❑ Inspection includes
observations of the nails for
clubbing.
Clubbed nails often occur in patients with
prolonged oxygen deficiency, endocarditis,
and congenital heart defects.
❑ Observe chest wall
movement for retraction
(i.e., sinking in of soft tissues of the chest
between the intercostal spaces) and use of
accessory muscles.
❑ Observe The shape of the
chest wall.
Conditions such as emphysema, advancing
age, and COPD (PPOK) cause the chest to
assume a rounded “barrel” shape
 Nursing Process : Physical Examination - Palpation

❑ Palpation of the chest provides assessment data in several

areas.
It documents the type and amount of thoracic excursion; elicits any
areas of tenderness; and helps to identify tactile fremitus, thrills,
heaves, and the cardiac point of maximal impulse (PMI).
❑ Palpation of the extremities provides data about the
peripheral circulation
(i.e., the presence and quality of peripheral pulses, skin
temperature, color, and capillary refill)
❑ Palpation of the feet and legs determines the presence
or absence of peripheral edema. Patients with alterations in cardiac
function such as those with heart failure or hypertension often have
pedal or lower-extremity edema. Edema is graded from +1 to +4
depending on the depth of visible indentation after firm finger
pressure
❑ Palpate the pulses in the neck and extremities to
assess arterial blood flow. Use a scale of 0 (absent pulse) to +4 (full,
bounding pulse) to describe what you feel. The normal pulse is +2;
and a weak, thready pulse is +1.
 Nursing Process : Physical Examination - Percusion

❑ Percussion detects the presence of abnormal fluid or air in the lungs.

❑ It also determines diaphragmatic excursion
 Nursing Process : Physical Examination - Auscultation

❑ Auscultation helps identify normal

and abnormal heart and lung
sounds
❑ Auscultation of the cardiovascular
system
Includes assessment for normal S1 and S2 sounds
and the presence of abnormal S3 and S4 sounds Crackles terdengar pada proses inspirasi. Suara crackles ini juga sering disebut dengan nama rales atau
(gallops), murmurs, or rubs. Identify the location, crepitation. ketika terdapat saluran udara yang sempit tiba-tiba terbuka hingga menimbulkan suara mirip seperti
suara “plop” yang terdengar saat bibir yang dibasahi tiba-tiba dibuka. Apabila terjadi di daerah bronchioles maka
radiation, intensity, pitch, and quality of a murmur.
akan tercipta fine crackles. Proses kedua, ketika gelembung udara keluar pada pulmonary edema.
Auscultation also identifies any bruit over the
carotid, abdominal aorta, and femoral arteries. Wheezing merupakan suara pernapasan berfrekuensi tinggi yang nyaring, dimana terdengar di akhir
ekspirasi / saat menghembuskan napas. Wheezing terjadi oleh karena adanya penyempitan saluran
❑ Auscultation of lung sounds pernapasan bagian ujung / dalam.
Involves listening for movement of air throughout
all lung fields: anterior, posterior, and lateral. Ronkhi merupakan suara napas tambahan yang bernada rendah yang terjadi akibat adanya
Adventitious, or abnormal, breath sounds occur penyumbatan jalan napas biasanya akibat adanya lendir. Ronkhi dapat terjadu pada inspirasi (saat
mengambil napas) maupun ekspirasi.
with collapse of a lung segment, fluid in a lung
segment, or narrowing or obstruction of an airway. Sridor terjadi karena penyumbatan aliran udara di tenggorokan atau di bagian belakang
tenggorokan

A pleural friction rub : The sound results from the movement of inflamed and roughened pleural surfaces against
one anotherA pleural friction rub is a manifestation of pleural disease, though its absence does not exclude this
 Diagnostic Test

❑ Arterial Blood Gases

❑ Pulmonary Function Test
❑ Bronchoscopy
❑ Lung Scan
❑ Thoracentesis
❑ Sputum Specimen
❑ Electrocardiogram
❑ Echocardiography
 Diagnostic Test

Degree PaO2 (mmHg) SaO2(%)

Normal 97 97
Normal Range >= 80 >= 95
Hipoksemia < 80 < 95
Ringan 60-79 90 – 94
Sedang 40 -59 75 – 89
Berat < 40 < 75

❑ Hipoksemia adalah keadaan dimana terjadi penurunan konsentrasi oksigen dalam darah
arteri (PaO2 normal 85-100 mmHg atau saturasi oksigen dibawah normal (<95%)
❑ Hipoksia adalah penurunan sejumlah oksigen yang terdapat di dalam jaringan
 The future starts today, www.umy.ac.id

not tomorrow.
Asuhan Keperawatan pada Pasien dengan Gangguan KDM Oksigenasi
Resti Yulianti Sutrisno, M.Kep., Ns., Sp.Kep.MB
PSIK FKIK UMY
 Nursing Process : Nursing Diagnoses – Nursing Outcome
SDKI
Respirasi
❑ Bersihan Jalan Napas Tidak Efektif
❑ Pola Napas Tidak Efektif
❑ Gangguan Pertukaran Gas
❑ Gangguan Ventilasi Spontan
❑ Resiko Aspirasi
Sirkulasi
❑ Penurunan Curah Jantung
❑ Perfusi Perifer tidak Efektif
❑ Intoleransi Aktivitas
SLKI SIKI
❑ Bersihan Jalan Napas, ❑ Manajemen jalan napas,
Tingkat Infeksi, Kontrol Latihan batuk efektif,
Gejala pemantauan respirasi,
❑ Pola Napas fisioterapi dada
❑ Pertukaran Gas, ❑ Pemantauan respirasi,
Keseimbangan Asam Basa dukungan ventilasi,
❑ Ventilasi Spontan pemberian posisi,
❑ Tingkat Aspirasi perawatan selang dada
❑ Manajemen Asam Basa :
Alkalosis / Asidosis
Respiratorik, Pemantauan
❑ Konservasi Engeri Respirasi, Terapi Oksigen,
❑ Manajemen Energi
Bersihan Jalan Napas Tidak Efektif
Ketidakmampuan membersihkan sekret atau obstruksi jalan nafas untuk mempertahankan jalan nafas tetap paten.

24
Pola Napas Tidak Efektif
Inspirasi dan/atau ekspirasi yang tidak memberikan ventilasi adekuat
Penyebab :
1. Depresi pusat pernapasan
2. Hambatan upaya napas (mis. nyeri
saat bernapas, kelemahan otot
pernapasan)
3. Deformitas dinding dada.
4. Deformitas tulang dada.
5. Gangguan neuromuskular.
6. Gangguan neurologis (mis
elektroensefalogram [EEG] positif, cedera
kepala ganguan kejang).
7. maturitas neurologis.
8. Penurunan energi.
9. Obesitas.
10. Posisi tubuh yang menghambat
ekspansi paru.
11. Sindrom hipoventilasi.
12. Kerusakan inervasi diafragma
(kerusakan saraf CS ke atas).
13. Cedera pada medula spinalis.
14. Efek agen farmakologis.
15. Kecemasan.
Gejalan dan Tanda Mayor : Gejala dan Tanda Minor :
Subjektif : 1. Ortopnea
Subjektif :
1. Dispnea Objektif :
1. Pernapasan pursed-lip.
Objektif : 2. Pernapasan cuping hidung.
1. Penggunaan otot bantu 3. Diameter thoraks anterior—
posterior meningkat
pernapasan.
2. Fase ekspirasi 4. Ventilasi semenit menurun
memanjang. 5. Kapasitas vital menurun
3. Pola napas abnormal 6. Tekanan ekspirasi menurun
(mis. takipnea. bradipnea, 7. Tekanan inspirasi menurun
8. Ekskursi dada berubah
hiperventilasi kussmaul
cheyne-stokes).
25
 Proses Ventilasi
1) Varians Tekanan • Pada saat belum terjadi inspirasi,
Udara tekanan udara di dalam paru-paru
sama dengan tekanan udara di
atmosfer (760 mmHg atau 1 atm).
• Pada saat inspirasi (menarik napas)
normal, gerakan diafragma mendatar
dan otot intercostalis eksterna akan
memperbesar rongga dada sehingga
menurunkan tekanan alveolar paru
menjadi 758 mmHg dibawah, yang
menyebabkan udara bisa masuk dari
lingkungan (atmosfer) ke saluran
pernapasan kemudian ke alveoli.
Gangguan Pertukaran Gas
Kelebihan atau kekurangan oksigenasi dan atau eleminasi karbondioksida pada membran
alveolus-kapiler.

PENYEBAB : Gejalan dan Tanda Mayor – GEJALA dan TANDA MINOR – Subjektif :
1. Ketidakseimbangan Subjektif : 1. Pusing.
ventilasi-perfusi. 1. Dispnea. 2. Penglihatan kabur.
2. Perubahan Gejalan dan Tanda Mayor –
membran alveolus- Objektif : GEJALA dan TANDA MINOR – Objektif :
kapiler. 1. PCO2 meningkat / menurun. 1. Sianosis.
2. PO2 menurun. 2. Diaforesis.
3. Takikardia. 3. Gelisah.
4. pH arteri 4. Napas cuping hidung.
meningkat/menurun. 5. Pola napas abnormal (cepat / lambat,
5. Bunyi napas tambahan. regular/iregular, dalam/dangkal).
6. Warna kulit abnormal (mis. pucat,
kebiruan).
7. Kesadaran menurun.
27
Terapi Oksigen
 Contoh Kasus

• Seorang laki-laki, 52 tahun, dirawat di Bangsal Penyakit dalam karena

penyakit PPOK (Penyakit Paru Obstruksi Kronis). Pasien mengeluh batuk
berdahak dengan dahak yang susah dikeluarkan dan sesak napas. Hasil
pemeriksaan fisik didapatkan frekuensi napas 28x/menit dan hasil
auskultasi ronkhi di posterior apical dekstra.
• Apakah diagnosis keperawatan, luaran, dan intervensi prioritas pada
kasus tersebut ?

29

Contoh Kasus
• Seorang laki-laki, 52 tahun,
dirawat di Bangsal Penyakit
dalam karena penyakit PPOK
(Penyakit Paru Obstruksi Kronis).
Pasien mengeluh batuk berdahak
dengan dahak yang susah
dikeluarkan dan sesak napas.
Hasil pemeriksaan fisik
didapatkan frekuensi napas
28x/menit dan hasil auskultasi
ronkhi di posterior apical dekstra.
• Apakah diagnosis keperawatan,
luaran, dan intervensi prioritas
pada kasus tersebut ?
Diagnosis Keperawatan : SIKI : Manajemen Jalan Napas
Bersihan Jalan Napas Tidak Efektif
b.d Sekret yang tertahan
• Monitor pola nafas (frekuensi,
kedalaman, usaha nafas)
DS :
• Monitor bunyi nafas tambahan
1. Pasien mengatakan sesak napas
(wheezing, ronkhi)
2. Pasien mengatakan batuk
• Monitor sputum (jumlah, warna)
berdahak dengan dahak susak
• Posisikan semi-fowler dan fowler
dikeluarkan
• Berikan minuman hangat
DO : • Lakukan fisioterapi dada, jika perlu
1. Hasil auskultasi ronkhi, • Berikan oksigen, jika perlu
2. frekuensi napas 28x/menit
• Anjurkan asupan cairan 2000
ml/hari, jika tidak kontraindikasi.
SLKI : Bersihan Jalan Napas
• Ajarkan teknik batuk efektif
Setelah dilakukan Tindakan
keperawatan 3x24 jam maka • Kolaborasi pemberian mukolitik,
bersihan jalan napas meningkat jika perlu
dengan kriteria hasil :
1. Sesak napas menurun
2. Batuk efektif meningkat
3. Suara napas tambahan
ronkhi/mengi menurun
4. Frekuensi napas menurun
30
menjadi 16-24x.menit
Nursing Process : Nursing Diagnoses – Nursing Outcome – NANDA NOC NIC

Nursing Diganosis Nursing Outcome

❑ Activity intolerance
❑ Status Pernapasan: Kepatenan JalanNapas
❑ Decreased cardiac output
❑ Status Pernapasan:Ventilasi
❑ Fatigue
❑ Status Pernapasan: PertukaranGas
❑ Impaired gas exchange
❑ Pencegahanaspirasi
❑ Impaired spontaneous ventilation
❑ Respon ventilasi mekanik:dewasa
❑ Ineffective airway clearance
❑ Keefektifan PompaJantung
❑ Ineffective breathing pattern
❑ Status Sirkulasi
❑ Ineffective health maintenance
❑ Perfusi jaringan
❑ Risk for aspiration
❑ Toleransi terhadapaktivitas
❑ Risk for imbalanced fluid volume
❑ Konservasi energi
❑ Risk for infection
❑ Risk for suffocation
 Nursing Process : Nursing Intervention – NANDA NOC NIC
Bersihan Jalan NapasTidak Efektif
❑ Manajemen jalan napas
❑ Penghisapanlendir
❑ Manajemen asma
❑ Fisioterapi dada
❑ Manajemen batuk
❑ Pemberian obat:inhalasi
❑ Terapi oksigen
❑ Monitor Pernapasan
❑ BantuanPenghentian merokok
Pola NapasTidakEfektif
❑ Terapioksigen
❑ Monitor Pernapasan
❑ Pemberianposisi
❑ Manajemenventiasi mekanik
❑ Perawatan selangdada
GangguanPertukaranGas
❑ Manajemen asambasa: asidosisrespiratorik
❑ Manajemen asambasa: alkalosisrespiratorik
❑ Monitor asambasa
❑ Terapioksigen
❑ Monitor pernapasan
❑ Perawatan emboli:paru
❑ Bantuanventilasi Intoleransi Aktivitas
❑ Terapiaktivitas
Penurunan Curah Jantung ❑ Perawatanjantung:
❑ Perawatan jantung rehabilitasi
❑ Manajemenenergi
❑ Perawatan jantung: akut
❑ Perawatanjantung: rehabilitasi ❑ Bantuan perawatandiri
❑ Peningkatantidur
❑ Pengaturanhemodinamik
❑ Monitor hemodinamik
❑ Manajemen elektrolit
❑ Manajeme Disritmia
❑ Terapi oksigen

Health Promotion
❑ Vaccinations.
Annual flu vaccines are recommended
for all people 6 months and older
❑ Healthy Lifestyle.
• Identification and elimination of
risk factors for cardiopulmonary
disease are important parts of
primary care.
• Encourage patients to eat a
healthy low-fat, high-fiber diet;
monitor their cholesterol,
triglyceride, high-density
lipoprotein (HDL), and low-density
lipoprotein (LDL) levels;
• reduce stress; exercise; and
maintain a body weight in
proportion to their height.
❑ Environmental
Pollutants.
Avoiding exposure to secondhand
smoke is essential to maintaining
optimal cardiopulmonary function.
Implementation
Acute Care
❑Dyspnea Management
Treatment of the underlying process causing dyspnea is then
followed with other therapies
• Pharmacological agents include bronchodilators, inhaled
steroids, mucolytics, and low-dose antianxiety medications.
• Oxygen therapy reduces dyspnea associated with exercise
and hypoxemia.
• Physical techniques such as cardiopulmonary reconditioning
(e.g., exercise, breathing techniques, and cough control),
relaxation techniques, biofeedback, and meditation
Airway Maintenance.
The airway is patent when the trachea, bronchi, and large airways are
free from obstructions. Airway maintenance requires adequate
hydration to prevent thick, tenacious secretions. Proper coughing
techniques remove secretions and keep the airway open. A variety of
interventions such as suctioning, chest physiotherapy, and nebulizer
therapy assist patients in managing alterations in airway clearance.
Hydration. Maintenance of adequate systemic hydration keeps
❑ mucociliary clearance normal. In patients with adequate hydration,
❑ pulmonary secretions are thin, white, watery, and easily
removable
❑ with minimal coughing. Excessive coughing to clear thick,
tenacious