NURSING CARE ON UPPER

RESPIRATORY TRACT INFECTION

PRODI S1 NURSING
FACULTY HEALTH SCIENCE
UNIVERSITT OF MUHAMMADIYAH TANGERANG
 COMPILED BY GROUP 5

1. Cantasyacitta Anggayasti/ 1614201013

2. M. Lutfi Baejuri /1614201027
3. Neng Mutamimah /1614201002
4. Rika Puspita Sari /1614201026
5. Siska Ainun Nisa /1614201003
6. Siska Mariani /1614201034

SEMESTER 4A
ANATOMY
 DEFINITION
Upper respiratory tract infections are
caused by viruses or bacteria. The disease
begins with heat accompanied by one or
more symptoms of sore throat or sore throat,
runny nose, dry stones or phlegm. ARI
always ranked first of the 10 most diseases
in Indonesia (Ministry of Health, RI, 2014).
 ARI CLASSIFICATION
Classification of respiratory diseases is differentiated
for age group under 2 months and for age group 2
months-5 years (Ministry of health, 2012) :
1. Age Group Less 2 Months

a. Weight ARI

b. Light ARI

2. Age Group 2 Months-5 Years

a. Weight ARI

b. Medium ARI

c. Light ARI
 ETIOLOGY
Etiology of ARI consists of more than 300
types of bacteria, viruses and rickets. Bacteria
that cause ARI include strains of Streptococcus,
Staphylococci, Pneumococcus, Hemofillus,
Bordetelia and Korinebakterium. Viruses that
cause ARI include Mixovirus, Adnovirus,
Koronavirus, Pikornavirus, Mikoplasma,
Herpesvirus and others (Hartono, 2013).
 RISK FACTORS
RISK FACTORS FOR ARI BAY (MARNI,2014) :
1. Demographic Factors a. Nutritional Status
Demographic factors consist b. Birth Weight
of 3 aspects, namely : c. Provision of breast milk
a. Gender d. Immunization Status
b. Age 3. Pollution Factors
c. Education The cause of the pollution
2. Biological Factors factor consists of 2 aspects,
Biological factors consist of namely (Marni, 2014) :
4 aspects, namely Marni, a. Chimney
2014 : b. Smoking Habit
 PATHOPHYSIOLOGY
The natural course of ARI disease is divided into 4 stages :
1. Prepatogenesis stage: the cause has been present but has not
shown any reaction.
2. Incubation stage: the virus destroys the epithelial layer and
the mucous layer. The body becomes weak especially when
the state of nutrition and previous resistance is low.
3. Early stage of disease: starting from the emergence of
symptoms of the disease, symptoms of fever and cough
develop.
4. The advanced stage of penyaklit, divided into four that can
be completely cured, healed with atelectasis, became
chronos and died of pneumonia.
 CLINICAL MANIFESTATIONS
While the signs of ARD symptoms according to MOH
RI (2012) are :
1. Symptoms of light ARI
A child is said to have light ARI if one or more of the
following symptoms : Cough, Hoarse, Cold, Hot
2. Symptom of medium ARI
A child is exposed to mild respiratory infection if
symptoms of miedium ARI with one or more of the
following symptoms :
a. Respiratory more than 50 times per minute in
children aged less than one year or more than 40
times per minute in children one year of age or older.
b. Temperature more than 390C
c. Throat is red
 Advanced ...
3. Symptom of weight ARI
A child is said to have severe weight ARI symptoms of
or medium ARI are present with one or more of the
following symptoms :
a. Lips or bluish skin

b. The nostrils flare at the breath

c. Unconscious child or consciousness decreases

d. Rapid pulse more than 160 times per minute

 SUPPORTING INVESTIGATION
1. Examination of culture/germs (swab) : the
results obtained are cultured bacteria (+) in
anccordance with the type of bacteria.
2. Blood count examination (deferential count) :
the rate of sedirmentation of blood increases
with the presence of leukocytosis and may also
be accompanied by the presence of
thrombocytopenia.
3. Examination of thorax photographs if needed.
(Benny, 2010)
 COMPLICATIONS
1. Pneumonia The complications
2. Bronchitis according to Dedi
Prasiyao (2007) is :
3. Laryngitis
1. Meningitis
4. Febrile
2. OMA
convulsion
3. Mastoiditis
(Soegijanto, 2009)
4. Dead
 MANAGEMENT
1. Medical
a. Supportive: increase endurance in the form of
adequate nutrition, giving multivitamins etc.
b. Antibiotics: Ideally based on the type of germs that
cause. Main aimed at S. pneumonia, H.Influensa
and S.Aureus
2. Nursings
The principles of ARI care include :
a. Increase rest at least 8 hours per day

b. Improve nutritious food

c. When fever give compress and drink a lot

NURSING CARE OF ARI
 CASE
Ms. A 18 year old was admitted to Magelang General Hospital
Bougenville room on January 04, 2010 with a continuous cough
with phlegm over 5 days, suddenly hot body cold and shortness
of breath. At the time of the assessment the patient complained of
shortness of breath, eating and drinking less, the throat was itchy
and difficult to swallow, lemes body like fever and feel warm,
and sputum issued yellowish white and thick. Patients are also
seen to spend ½ of the portion given by the hospital, the patient
seems to feel pain and grimace while swallowing, sleeping semi-
fowler position with pillow, visible congested, cough with
phlegm, there is pain swallowing, while walking to the bathroom
looks supported. Result of examination in get data: TTV: TD =
120/90 mmHg, N = 84 times / min, S = 37ºC, RR = 28 times /
min, LED laboratory examination: 4/10 mm / hour.
 ASSESSMENT
1. Biodata
8) Date of admission: 4
a. Patient identity
January 2010, at 23.50
1) Name: Ms. A. P WIB
2) Age: 18 years 9) Medical dx: Acute
3) Gender: Female respiratory tract
4) Education: SMK
infection
b. Person in charge
5) Religion: Islam
1) Name: Mr. J
6) Address: Magelang
2) Occupation: PNS goal
7) No Medical Record:
III
22.06.02.4319
3) Address: Magelang
 Advanced...
2. Main complaint : Persistent cough with phlegm
3. Current disease history :
Patients come via UDG with complaints since
afternoon after street vendors, suddenly hot body cold,
cough with 5 days phlegm, there is sputum, shortness of
breath (with supination position). At the time of
assessment the patient complained of shortness of breath,
eating and drinking less, throat itchy and hard to swallow,
lemes body like fever and feel warm, and sputum issued
yellowish white and thick. Patients are also seen to spend
½ portion given by the hospital, the patient is seen feeling
pain and grimacing while swallowing, semi fowler
sleeping position with pillow pillows, look as soon as,
cough with phlegm, there is pain of swallowing, while
walking to the bathroom seen lavered.
 Advanced...

4. Past medical history :

Patients have never had such a disease now.
And the patient has never been hospitalized
before.
5. Family disease history : No family suffers the
same illness.
6. Social History : Near the patient's house there is
a stack of secondhand goods.
 Advanced...
7. Physical examination
a. General situation: Weak and shortness of breath

b. Awareness: Composmentis

c. TTV: TD = 120/90 mmHg, N = 84 times / min, S =

37ºC, RR = 28 times / min
d. BB: 44 kg

e. TB: 158 cm

f. IMT: 17,63 (skinny)

g. Head: Mesocephal

h. Hair: Not easy to fall out, black color, no dandruff.

 Advanced...

i. Eyes: The conjunctiva is not anemic, the sclera is not

jaundiced, does not use visual aids, not color blind.
j. Ears: Good hearing, no cerumen, no hearing aid.
k. Nose: There is no polyp, no secret, no sense of smell.
l. Mouth: The tongue is not dirty, clean teeth, dry lips,
no caries.
m. Neck: There is no enlargement of the thyroid gland.
n. Throat: Throat ache and itch, and difficulty
swallowing.
 Advanced...
o. Chest :
1) Lung
a) Inspection: Lung development is the same.
b) Palpation: Vocal fremetus right and left alike.
c) Percussion: no fluid accumulation.
d) Auscultration: Whezing (-), ronchi (+), vesicular.
2) Heart
a) Inspection: Icus cordis is not visible.
b) Palpation: Icus cordis palpable in the mid linea
clavicle sinistra 5, ± 2cm
c) Percussion: S1 and S2 regular.
d) Auscultration: gallop (-), nuts (-).
 Advanced...
p. Abdomen:
1) Inspection: flat stomach, no lesions

2) Auscultration: Bowel bowel 10 times / minute

3) Palpation: There is no enlargement of the liver. There

is no mass
4) Percussion: Thympani

q. Upper extremity: Good movement, no lesions, RL

infusion in left hand.
r. Lower extremity: Good movement, no lesions, no oedem.
s. Genetalia: There is no venereal disease, no pain.
t. Skin: Good skin turgor, warm skin felt.
u. Extremities: sensation to sharp (+), to heat (+).
 Advanced...
v. Assessment of pain in the throat:
1) Permitten: Pain occurs when coughing and
swallowing
2) QUALITY: Like being stabbed
3) Region: Pain thrown in the throat
4) Scale: Scale ± 3
5) Time: During coughing and swallowing
8. Data Support
a. Ronthent thorax on January 5, 2010:
b. COR: The shape and magnitude of normal
c. Pulmones: The aspect of calm, no visible signs of
tuberculosis process activity
d. Laboratory : LED: 4/10 mm / hour
DATA ANALYSIS
 DIAGNOSIS
1. The gas exchange disruption is related to the
lack of oxygen supply
2. Acute pain associated with inflammation in
the mucous membranes of the pharynx and
tonsils
3. Disorders of nutritional needs related to
anorexia
INTERVENTION
IMPLEMENTATION