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Diagnoses Impaired gas exchange related to effects of alveolar capillary membrane changes Short target : during 1x24 hour difference ventilate pervusi do not happened With criteria result of " Normal Respiration " Po2 mount and downhill pco2 Goals Target of length : during 3x24 hour do not happened damage of transfer gas
Planning Interventions 1. teaching respiration every 2-4 hours , its deepness, usage of breath muscle, nostril and lobe of is existence of coughing
Implementations
Evaluations S: asphyxia say still client O: - client seen to oppress - Client still cough A: problem not yet been overcome P: intervention in continuing.
1.
1.
teaching
respiration every 2-4 hours , its deepness, usage of breath muscle, nostril and lobe of is existence of coughing
2.
2. auscultation breath sound every 2-4 hour 3. heightening. part of moment head sleep 30-40 with head a little extension 3. Watering down client for the breathing 2. Assessing degree of bronkospasme.
auscultati
3.
Heighteni
ng. part of moment head sleep 30-40 with head a little extension
4. give O2 if when
needed
4. Improving respiration.
distress omission and cyanosis referring to hypoxemia.
4.
Giving
O2 if when needed
5. collaboration with
doctor " Gift medicine with indication: bronchodilator " Monitor blood gas analysis and asymmetry pulse
represent the root cause commute for gas in bronchi annoyer pressure CO2 usually downhill and improving pressure O2 so that hypoxemia
5.
Collabora
ting with doctor " Gift medicine with indication: bronchodilator " Monitor blood gas analysis and asymmetry pulse S: Client say
Target of length : during 3x24 hours cleanness effective airway. Short target : during 1x24 hours secret inexistence with criterion " breath frequency. less than 40x / minute " there no secret " Negative Ronci
1. Hear and note breath voice 2. Monitor exhalation note expiration and inspiration
1.
Heari
cough O: - cough still phlegm - voice rales - respiration 25x/ second A: problem overcome some of P: intervention in continuing.
2.
Monit
oring exhalation note expiration 3. watering down client to breathe and inspiration
3.
Assis
ting client for 4. secret which jell to represent the root cause exhalation annoyed, suction required to [release] balmy position ( semi fowler )
4.
Cond
secret
5. collaboration
with doctor " giving medicine with indication : inhalers, antimicrobial and bronchodilator " Monitor : blood gas analysis, thorax roentgen Is not effective 3 exhalation pattern relate to dyspneu Target of length : During 3x24 hours effective breath pattern 2. Giving oxygen Short target : During 1x24 hours no dyspneu and no nose lobe therapy according to indication 3. Arrange semi position 1. observation vital sign every 4 hours
5. secret a which jell to represent the root cause transfer of gas in breath channel annoyed. co2 pressure usually mount and downhill o2 pressure so that hypoxemia
medication of suction 5. colla boration with doctor " giving medicine with indication : inhalers, antimicrobial and bronchodilator " Monitor : blood
S: Client still oppress O: - visible client oppress - cough (+) A: problem not yet been overcome P: intervention
downhill of kolaps of airway activity and dispneu 4. Collaboration with doctor: Giving bronchodilator, antikolergenik, and anti inflammation Change 4 requirement body relate Anorexia of Target of length : During 3x 24 hours requirement of nutrient fulfilled Short target : During 1x24 client hours do not anorexia With criteria Heavy increase of body 4. Medicine which in] giving can improve effectively of airway.
in continuing
4.
doctor: Giving
Colla
borating with
1.
Give the clarification at important family and client of food to disease recovering
1.
Giving
S: queasy word still client O: - portion eat do not finished - queasy visible client A: problem not yet been overcome P: intervention in continuing.
1.
Giving the clarification at
2.
Teaching client an ability to eat
2.
Client
2.
Portion eat finished 3. give high calories and high protein food and vary and presented by food with small portion but in a state of warmness 4. oral hygiene consecutively
Teaching client
3.
Adding
an ability to eat
3.
Giving high calories and high protein food and vary and
4.
Aroma
5.
Good for
4.
conducting oral hygiene consecutively
6.
nutrient digestion, balance. as according to requirement 7. collaboration with doctor for the giving of vitamin 8. given oxygen addition in appropriate size measure collaborations with doctor
6.
Collaborating craftily nutrient to increase amenity in nutrient
7.
8. oxygen can balance co2 in blood so that can degrade dyspnue and also food earn
7.
Collaborating with doctor for the giving of vitamin
8.
giving oxygen addition in appropriate size measure collaborations with doctor