NURSING CARE BASIC CONCEPT OF EMERGENCY NURSING NURSING WITH

CASE OF FAILURE

A.Definition

Emergency Nursing is a comprehensive nursing service given to patients with life-

threatening acute or sick injuries.

Breath failure is an inadequate gas exchange resulting in hypoxemia, hypercapnea

(increased arterial carbon dioxide concentration) and acidosis. (Arif Muttaqin, 2008)

B. Scope of activities

1. Prevent death and disability in emergency patients until they can live and function

again in the community.

2. Referring to emergency patients through a referral system to obtain more adequate

treatment.

3. Management of disaster victims

C. Purpose of first aid:

1. Save life

2. Preventing pain getting worse

3. Improve recovery
D. NURSING CARE

Primary Study

Airway

• Increased respiratory secretion

• Breath sounds krekels, ronki and wheezing.

Breathing

• Respiratory distress: nasal lobe breathing, tachypneu / bradycardia, retraction.

• Use respiratory accessory muscles.

• Difficulty in breathing: air hunger, diaphoresis, cyanosis.

Circulation

• Decreased cardiac output: anxiety, lethargy, tachycardia

• Headache

• Impaired level of consciousness: anxiety, anxiety, mental disorder, sleepiness

• Papiledema

• Decreased urine output

According to basic data collection by Doengoes

 Diagnose 1 :

Gas exchange disorders that are associated with disruption of air flow to the alveoli or
major parts of the lungs, retained secretion, disease processes, inadequate ventilation.

Objective: After being given nursing care within 1x24 hours of gas exchange improved.

 The frequency of breathing is 18-20 / minute

 Pulse rate is 75-100 / minute
 Normal skin color, no dipnea, and arterial blood gas (GDA) within normal limits.
 Can demonstrate effective coughing
 Results of normal blood gas analysis:

PH (7,35 - 7,45)

PO2 (80 - 100 mmHg)

PCO2 (35 - 45 mmHg)

ational Intervention Plan

 Monitor respiratory status every 4 hours, GDA results, intake and output. To
identify indications towards progress or deviation from client outcomes
 Place the client in the semifowler position. The upright position allows better lung
expansion.
 Advise intravenous therapy as recommended. To enable rapid rehydration and can
assess vascular conditions for emergency medications.
 Give oxygen through nasal cannula 4 L / minute then adjust to the results of
PaO2. Giving oxygen reduces the burden of respiratory muscles.
 Collaboration with the medical team in providing appropriate treatment and
observing if there are signs of toxicity. Treatment to restore bronchial conditions
like previous conditions.
 Diagnose 2 :

The ineffectiveness of airway clearance is associated with an increase in secret / mucus

production, limited chest movements, pain, weakness and fatigue.

Purpose: Within 1x24 hours after being given an effective airway hygiene intervention,
the client will demonstrate the ability to improve and maintain the effectiveness of the airway.

Result criteria:

 No additional breath sounds and wheezing / ronchi (-)

 Normal client breathing (16-20x / minute) without the use of an auxiliary breathing
muscles.
 Can demonstrate effective coughing
 Can state strategies to reduce the secretion of secretions

Rational Intervention Plan

 check the color, viscosity, and amount of sputum Sputum characteristics can
indicate the severity of obstruction
 Setting the semifowler position Increases chest expansion
 Teach effective coughing methods A controlled and effective cough can facilitate
the removal of secretions attached to the airway
 Assist the client in deep breathing exercises Maximum ventilation opens the
lumen of the naps and increases the movement of secretions into the large airway
to be removed
 Maintain fluid intake at least 2500 ml / day unless indicated
 Adequate hydration helps to dilute the secretions and activate airway cleansing.
 Perform chest physiotherapy with postural drainage, percussion and chest
fibration techniques. Chest physiotherapy is a strategy for removing secretions
 Collaboration of drug delivery
Bronchodilator class B2

• Nebulizer (via inhalation) with terbutaline groups 0.25 mg, fenoterol HBr 0.1%

Solution, orciprenaline sulfur 0.75 mg

• Intravenous with theophyline group ethilenediamine (Aminophylline) IV bolusb

5-6 mg / kgBB