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DEFINISI DAN BATASAN KARAKTERISTIK MASALAH KEBUTUHAN
OKSIGENASI
Kategori : Fisiologis
Sub Kategori : Respirasi
0001 Bersihan Jalan Napas Tidak Efektif
0002 Gangguan Penyapihan Ventilator
0003 Gangguan Pertukaran Gas
0004 Gangguan Ventilasi Spontan
0005 Pola Napas Tidak Efektif
0006 Risiko Aspirasi
BERSIHAN JALAN NAPAS
Definisi
Ketidakmampuan membersihkan
sekret atau obstruksi jalan napas
untuk mempertahankan jalan
napas tetap paten.
GANGGUAN PENYAPIHAN VENTILATOR
Definisi:
Ketidakmampuan beradaptasi dengan pengurangan
bantuan ventilator mekanik yang menghambat dan
memperlama proses penyapihan
RISIKO ASPIRASI
Berisiko mengalami masuknya sekresi gastrointestinal,
sekresi orofaring, benda cair, atau padat ke dalam
saluran trakheobronkial akibat disfungsi mekanisme
protektif saluran napas
ANAMNESIS GANGGUAN SISTEM PERNAPASAN
JENIS POLA NAPAS
CHEST SHAPES
PALPATING THE CHEST
CHEST EXCURTION
TACTILE FREMITUS
CHEST PERCUSSION
Bronchial sounds heard outside
of their normal locations: Fluid or
AUSCULTATION consolidated tissue, such as in pneumonia.
Diminished breath sounds: Thick, obese, or
muscular chest wall, poor inspiratory effort,
emphysema with air trapping, pleural
effusion.
Absent breath sounds: Missing lung/lobe,
airway obstruction, pneumothorax.
Crackles/rales:Pulmonary edema,
pneumonia, atelectasis, and upon arising in
elderly people.
Velcro rales: Pulmonary fibrosis.
High-pitched, sibilant wheezes:
Bronchospasm, asthma, COPD without
infection.
Low-pitched sonorous wheezes/rhonchi:
Uncleared secretions, bronchitis,
pneumonia,tumors.
Stridor: Laryngeal or tracheal obstruction,
epiglotitis, viral croup.
Pleural friction rub: Inflammation of pleura.
Suara bronkial terdengar di luar lokasi normal mereka: Jaringan cairan atau
gabungan, seperti pada pneumonia.
Suara nafas yang berkurang: Dinding dada yang tebal, gemuk, atau berotot, usaha
inspirasi yang buruk, emfisema dengan perangkap udara, efusi pleura.
Suara napas tak ada: Hilangnya paru-paru / lobus, sumbatan jalan nafas,
pneumotoraks
Retak / rales: Edema paru, pneumonia, atelektasis, dan pada saat timbul pada
orang tua.
Rompi velcro: fibrosis paru.
Nyeri bernada tinggi, sibilant: Bronkospasme, asma, PPOK tanpa infeksi.
Obsesi nyaring / rhonchi bernada rendah: Sekresi tak jelas, bronkitis, radang paru-
paru, tumor.
Stridor: Obstruksi laring atau trakea, epiglotitis, kelompok virus.
Gesekan gesekan pleura: Peradangan pleura
NORMAL BREATH SOUNDS
ABNORMAL BREATH SOUNDS
1. Rales/ Crackles
Rales or crackles are discontinuous sounds resulting
from air bubbling through moisture in the alveoli or from
collapsed alveoli popping open. Crackles tend to occur at
the end of inspiration, in the terminal bronchioles and
alveoli.
Rales associated with long-standing chronic lung disease
or with interstitial pulmonary fibrosis
Rales atau crackles adalah suara terputus-putus
akibat gelembung udara melalui kelembaban
di alveoli atau dari alveoli yang roboh yang
terbuka. Crackles cenderung terjadi pada
akhir inspirasi, di terminal bronchioles dan
alveoli.
Rales terkait dengan penyakit paru kronis yang
sudah berlangsung lama atau dengan fibrosis
paru interstisial
2. Rhonchi/Wheezes
Wheezes are continuous sounds caused by the
narrowing of an airway by spasm, inflammation,
mucus secretions, or a solid tumor. Pitch is
determined by the relative tightness/narrowness
of the airway. For example, in asthma, tightly
constricted small airways produce very high-
pitched, or sibilant, wheezes.
Wheeze
3. Stridor
Stridor is a harsh, high-pitched, continuous
honking sound resulting from an upper airway
obstruction, a partial obstruction, or a spasm
of the trachea or larynx. A person with stridor
is usually in acute respiratory distress and
requires immediate intervention.
4. Friction Rub
A friction rub is different from all other adventitious sounds,
because it occurs between the pleural layers, not in the
lung. It results from the rubbing together of the parietal
and visceral layers of an inflamed pleura, which produces
a high-pitched grating or squeaking sound. The rub may
occur during both inspiration and expiration, but because
it is not in the lung, it will never be affected by coughing. A
pleural friction rub is associated with pleuritis, so people
often complain of pain in the area of the rub, especially
with deep inspiration
TEMUAN UMUM PADA BBRP PENYAKIT SISTEM PERNAPASAN
1. ASTHMA
Use of accessory muscles
Intercostal and supraclavicular retraction
Chest tightness
Dyspnea, respiratory rate >30/min
Increased pulse with PVCs, increased or decreased BP
Pulsus paradoxus >12 mmHg
Crackles, rhonchi, wheezes, decreased or absent
breath sounds
Early in diseaseexpiratory wheezes
Late in diseaseinspiratory and expiratory wheezes
Hyperresonance
Decreased tactile fremitus
Decreased chest excursion
2. BRONCHITIS
Increased AP diameter
Increased costal angle
Increased use of accessory muscles
Cardiac enlargement
Decreased excursion
Decreased tactile fremitus
Hyperresonance at bases, dullness over exudate
areas
Crackles, rhonchi, wheezes
Breath sounds decreased at bases
3. EMPHYSEMA
Rapid, shallow respiration
Use of accessory muscles
Distant heart sounds, right-sided S3
Tachycardia with arrhythmias
Hyperresonance at bases or in all lung fields
Decreased excursion
Decreased tactile fremitus
Increased AP diameter
Increased costal angle
Decreased breath sounds
4. Lung Cancer
Change in respiratory pattern
Wheezes
Decreased breath sounds over affected lung
Chest, shoulder, or arm pain
5. Pleural Effusion
Decreased excursion on affected side
Decreased tactile fremitus on affected side
Dullness on percussion
Decreased or absent breath sounds
Friction rub with initial inflammation; rub disappears as fluid develops
6. Pneumonia
Tachypnea
Use of accessory muscles
Asymmetrical chest movement
Decreased excursion
Increased tactile fremitus
Crackles, rhonchi
Bronchial breath sounds
Positive bronchophony
Dullness on percussion
7. Pneumothorax
Asymmetrical excursion
Decreased fremitus
Hyperresonance
Absent breath sounds
8. Tuberculosis
Dyspnea.
Productive cough with nonpurulent, blood-streaked
sputum.
Hemoptysis.
Pleuritic or dull chest pain.
Chest tightness.
ALTERATIONS IN RESPIRATORY FUNCTION
Assessment
1. Riwayat Kesehatan
2. Pemeriksaan fisik
3. Test Diagnostik
4. Pemeriksaan Darah
ASSESSMENT: NURSING HISTORY
1. Inspection
2. Palpation
3. Percussion
4. Auscultation
INSPECTION OF
CARDIOPULMONARY STATUS
1. Cyanotic mucous membranes
2. Pursed lip breathing
3. Jugular neck vein distention
4. Nasal faring
5. Use of accessory muscles
6. Peripheral or central cyanosis
7. Edema
8. Clubbing of fingertips
9. Altered breathing patterns
10.Pale conjunctivae
Marked clubbing of the nails.
25 Clubbing
Clubbing nails
PALPATION
1. Activity Intolerance
2. Ineffective Tissue Perfusion
3. Decreased Cardiac Output
4. Impaired Gas Exchange
5. Ineffective Airway Clearance
6. Ineffective Breathing Pattern
7. Fatigue
8. Anxiety
PLANNING FOR CARE
1.Vaccinations
2.Healthy Lifestyle
3.Environmental pollutants
IMPLEMENTATION: ACUTE CARE
1. Dyspnea Management
2. Airway Management
3. Mobilization of Airway Secretions
4. Maintenance and Promotion of Lung
Expansion
5. Maintenance and Promotion of Oxygenation
6. Breathing Exercises
7. Hydration
DYSPNEA MANAGEMENT
1. Oropharyngeal
2. Nasopharyngeal
3. Orotracheal
4. Nasotracheal
5. Tracheal
PROMOTION OR MAINTENANCE OF LUNG
EXPANSION
Positioning of patient
Incentive Spirometer
Chest tubes
OXYGEN THERAPY
Inisiasi
Aerosol Basil berdiam di alveoli Makrofag pecah
sistem
yang dan diliputi oleh makrofag dan mengeluarkan
imuniti
terinfeksi alveolar bakteri
innate
Tjd kalsifikasi
Tidak sukses lalu
dan fibrosis
tjd fibrosis
Necrotic
semiliquid
Necrotic semiliquid Mukus
Penghantaran
getaran suara Ronki kering
meningkat
Kininogen Kinin
Mendorong Merangsang
sistem kemotaksis
peningkatan reseptor nyeri di
komplemen
permeabilitas pleura parietal
kapiler
NYERI DADA
DEMAM DAN ANEMIA DEF. BESI
Pemeriksaan fisik
Pada tahap dini sulit diketahui
Ronchi basah, kasar dan nyaring.
Hipersonor/timpani bila terdapat kavitas
yang cukup
Pada keadaan lanjut atropi dan retraksi
interkostal dan fibrosis
Bila mengenai pleura terjadi effusi pleura
(perkusi memberikan suara pekak).
PEMERIKSAAN TAMBAHAN
Sputum culture : positif untuk mycobakterium
tuberculosis pada stadium aktif
Ziehl Neelsen (azid-fast Staind applied to
smear of body fluid) : positif untuk BTA
Skin test (PPD,Mantoux, tine, vollmer patch) :
reaksi positif ( area indurasi 10 mm atau
lebih, timbul 48 72 jam setelah injeksi
antigen intradermal) mengindikasikan infeksi
lama dan adanya natibodi tidak
mengindikasikan penyakit sedang aktif.
Elisa /western blot : dapat menunjukkan adanya
HIV
Chest X-Ray : dapat memperlihatkan infiltrasi
kecil pada lesi awal di bagian paru-paru bagian
atas, deposit kalsium pada lesi primer yang
membaik atau cairan pada effusi.
Perubahan mengindikasikan TB yang lebih
beratv dapat mencakup area berlubang dan
fibrous.
Histologi atau culture jaringan ( termasuk
kumbah lambung, urine dan CSF, biopsi kulit ) :
positif untuk mycobacterium tuberculosis.
Needle Biopsi of Lung Tissue : positif untuk
granuloma TB, adanya sel-sel besar yang
mengindikasikan nekrosis.
Elektrolit : mungkin abnormal tergantung dari
lokasi dan beratnya infeksi : misalnya
hiponatremia mengakibatkan retensi air,
mungkin ditemukan pada TB paru kronik lanjut.
ABGs : mungkin abnormal, tergantung lokasi,
berat dan sisa kerusakan paru.
Bronchografi : merupakan pemeriksaan khusus
untuk melihat kerusakan bronchus atau
kerusakan paru karena TB.
Darah : lekositosis, LED meningkat.
Test Fungsi Paru : VC menurun, dead space
meningkat, TLC meningkat dan menurunnya
saturasi oksigen yang merupakan gejala
sekunder dari fibrosis/infiltrasi parenchim
paru dan penyakit pleura.
PENATALAKSANAAN
Tujuan :
1. Menyembuhkan penderita
2. Mencegah kematian
3. Mencegah kekambuhan
1. Tahap intensif
2. Tahap lanjutan
TAHAP INTENSIF
Mencegah kekambuhan
KATEGORI 1 (2RHZE / 4H3R3)
1. Kasus kambuh
2. Kasus gagal
Berat :
Serius
OAT stop
Rujuk