Nama : Hermawati

Nim : 21117063

Prodi : PSIK IB

No Nursing Diagnosa Nursing Outcome Classification(NOC) Nursing Intervention Classification(NIC) Implementation Evaluations

1 Ineffective Respiratory status: Airway Management  open the airway using the S : The patient say that not feeling
Breathing Pattern After threatment 4x24 hours,status chin lift. shortness of breath
related to fatigue. patient is normal,with indicators: Activity:  semi fowler position to
No Indicators Now Target  Open the airway using the chin comfort patient. O : Vital sign patient is normal
Subjective Data:  Nurse ask to patient that And patient not use the Oxygen.
lift or jaw thrust technique,as
- Dyspnea 1 Respiratory 2 4 patient want using
appropriate.
rhythm oxygenation or not.and
 Position patien to maximize patient respon want to us A : Effective Breathing Pattern
2 Respiratory 1 4
ventilation potential (e.g.,semi oxygen.
Objective Data: frequency
3 Inspiration 1 5
fowler 45 degree)  chest physical therapy to
-Respiratory Rate 12-
18 x/minute depth  Identify patient requiring make patient have cough P : Keep the Condition
- Dyspnea 4 Auscultation 3 5 actual/potential airway inserted  education how to
sound of  Perform chest physical therapy,as encourage
respiratory appropriate. slow,deep
 Encourage slow,deep breathing,turning and
Scale: breathing,turning and coughing. coughing.
1 = High  Auscultate breath sounds,noting
2 = Severe areas of decreased or absent
3 = Moderate ventilation and presence of
4 = Low adventitious sounds.
5 = Normal
.