English Assignment III

Courses :

English in Nursing

Compiled By :

RESKA VERA PUSPITA

113063C218060

NURSING STUDY PROGRAM

HIGH SCHOOL OF HEALTH SCIENCES SUAKA INSAN
BANJARMASIN
2019

Nursing Plan
No Nursing Diagnoses Objectives And Outcome Intervention
Criteria
1 Ineffectiveness Of The NOC: NIC:
Airway Clearance  Respiratory status: Airway Suction:
Definition: inability to Ventilation a. Make sure the tracheal
clear secretions or  Respiratory Status: suctioning needs
obstruction of the Airway Patency b. Auscultate the breath
respiratory tract to  Aspiration Control sounds before and after
maintain airway hygiene suction
Characteristic After nursing action, the c. Ask the client to breathe
Boundaries: client shows the effectiveness before suction.
 no cough of breathing with the outcome d. Give oxygen using nasal
 additional breath criteria: canul
sounds a. Demonstrating effective e. Use a sterile tool every
 changes in breathing coughing and clean time you take action.
frequency breathing sounds, no f. Encourage the patient to
 changes in breathing cyanosis, and dyspneu. rest and breathe deeply
rhythm b. Shows patent airways after the catheter is
 cyanosis c. Able to identify and removed from the
 difficulty speaking or prevent causative factors nasotracheal
making sounds g. Observation of oxygen
status
 decreased breath
h. Teach the family how to
sounds
do suction
 dispneu
i. Stop suction and give
 excessive amounts of oxygen if the patient
sputum shows bradycardia,
 ineffective cough increasing the saturation
 orthopneu of okisgen
 fidgety
 eyes wide open Airway Management:
factors related to: a. Open the airway use the
a. Environment: passive chin lift technique or jaw
smokers, smoke, trust if necessary
smoke. b. Position the patient to
b. Airway obstruction: maximize ventilation
airway spasm, retained c. Patient identification of
secretions, many the need for the
mucus, an artificial installation of an artificial
airway, bronchial airway
secretions, exudate in d. Install opa if necessary
the alveoli, the e. Do chest physiotherapy
presence of foreign f. Remove the secretions
objects in the airway with an effective cough or
c. Physiological: allergic suction
airway, asthma, chronic g. Auscultate the breath
obstructive pulmonary
 disease, bronchial wall
hyperplation, infection,
neuromuscular
dysfunction
No Nursing Diagnoses
2 Activity intoleranc:
Definition: Inadequate
psychological or
physiological energy to
continue or complete the
activities of daily life that
must or want to be done.
Characteristics:
 An abnormal blood
pressure response to
activity
 The response of
abnormal heart
frequencies to activity
 ECG changes that
reflect arrhythmias
 ECG changes that
reflect ischemia
 Discomfort after
activity
 Dipsnea after activity
 Express feeling tired
 Express feeling weak
Related Factors:
a. Bed rest or
immobilization
b. General weakness
c. Imbalance between
oxygen supply and
demand
d. Immobility
e. Monotonous lifestyle
sounds
h. Do suction on opa
i. Give a bronchodilator if
necessary
j. Monitor respiration and
oxygen status
Nursing Plan
Objectives And Outcome Intervention
Criteria
NOC: NIC:
 Energy conservation Activity Therapy:
 Activity tolerance a. Collaborate with medical
 Self Care: ADLs rehabilitation personnel in
After nursing action, the planning appropriate
client shows the effectiveness therapeutic programs
of breathing with the outcome b. Help clients to identify
criteria: activities that can be done
c. Help to choose activities
 Participate in physical that are consistent with
activity without an physical, psychological
increase in blood and social abilities
pressure, pulse and RR d. Help to identify and
 Able to do daily activities obtain the resources
(ADLs) independently needed for the desired
 Vital signs are normal activity
e. Help to get activity aids
 Psychomotor energy
such as wheelchairs,
 Weakness level
cranks
 Ability to move: with or f. Help to identify the
without the aid of a tool
activity you like
 Adequate g. Help clients to make a
cardiopulmonary status training schedule at
 Good circulation status leisure
 Respiratory status: gas h. Help the patient / family
exchange and adequate to identify deficiencies in
ventilation activity
i. Provide positive
reinforcement for those
who are active
j. Help patients to develop
self-motivation and
reinforcement
k. Monitor physical,
emotional, social and
spiritual responses