Nursing Diagnosis for Disseminated Intravascular Coagulation (DIC)

Disseminated Intravascular Coagulation (DIC) can occur in virtually all persons without distinction of race, sex, and age. The symptoms of DIC, generally strongly associated with the underlying disease, plus additional symptoms due to thrombosis, embolism, organ dysfunction, and bleeding. Disseminated Intravascular Coagulation (DIC) is a complex diagnosis that involves a component of blood clots as a result of other diseases that precede.



Definition of Disseminated Intravascular Coagulation

Disseminated Intravascular Coagulation is a syndrome characterized by bleeding / clotting disorders are caused by the formation of plasmin which is a specific plasma protein that is active as a fibrinolytic in getting the circulation (Healthy Cau's)

In general, disseminated intravascular coagulation (DIC) is defined as a complex disorder or blood clotting disorder due to excessive stimulation of procoagulant and anticoagulant mechanisms in response to injury (Yan Euphrates Sembiring, Paul Tahalele)


Etiology of Disseminated Intravascular Coagulation

Bleeding occurs due to the following matters:

• Hypofibrinogenemia.
• Thrombocytopenia (a common cause of abnormal bleeding, can occur due to insufficient production of platelets by the bone marrow, or due to increased destruction of platelets).
• Circulating anticoagulant in blood circulation.
• Excessive fibrinolysis.

Diseases that predispose to DIC is as follows:

• Infections (dengue hemorrhagic fever, sepsis, meningitis, severe pneumonia, tropical malaria, rickettsial infection by some types). Where bacteria release endotoxins (a substance that causes clotting activation).
• Pregnancy complications (placental abruption, intrauterine fetal death, amniotic fluid embolism).
• After surgery (lung surgery, bypass cardiopulmonal, lobectomy, gastrectomy, splenectomy).
• malignancies (prostate carcinoma, lung carcinoma, acute leukemia).
• Acute liver disease (acute liver failure, obstructive jaundice).
• Palepasan severe trauma occurs to the network with a large number of blood vessels. The release coincides with hemolysis and endothelial damage that would release blood clotting factors in large numbers then activates blood coagulation systemically.

Clinical Manifestations of Disseminated Intravascular Coagulation

1. Bleeding from puncture area, wounds and mucous membranes in patients with shock, obstetric complications, sepsis (widespread infection), or cancer. If bleeding occurs under the skin, vascular lesions will appear.
2. Changes in the level of consciousness.
3. Cyanosis and tachypnea (increased respiratory rate) due to poor tissue perfusion and oxygenation are common. Splotches on the skin indicates tissue ischemia.
4. Hematuria (blood in the urine) due to bleeding or oliguria (decreased urine output) due to poor perfusion.

Complication

• Clot which formed much will cause obstruction or hindrance of blood flow in all organs of the body. Organ failure can occur at large. The mortality rate of more than 50%.
• Shock.
• Acute tubular necrosis.
• Pulmonary edema.
• Chronic renal failure.
• Convoluted.
• Coma.

Assessment for Disseminated Intravascular Coagulation (DIC)

1. Predisposing factors:

• Septicemia (most common cause).
• Obstetric complications.
• Severe and extensive burns.
• Neoplasia.
• Liver disease.
• Trauma.

2. Patterns of health functions
a. Health Perception and Management

• nausea, vomiting
• minus liquid
• Ht (if that exit the plasma, hematocrit rise; wrote out all that blood, Ht down)

b. Nutritional metabolic

• Impaired elimination patterns, both bladder and bowel movements. In bowel constipation or diarrhea occurs. Melena
• Hematuri
• Hematemesis

c. Activity exercise

• Changes in vital signs, SaO2 (descending)
• The need for assistance to meet their daily needs.
• Weak muscle contraction.

d. Sleep rest

• Changes meet the needs sleep (quality and quantity).

e. Cognitive-perceptual

• abdominal pain; pain, coldness in the fingers accompanied by numbness and tigling.

f. Role relationship

• With the long treatment, there will be obstacles in carrying out its role as before.

g. Sexuality reproductive

• Decreased sexual function
• Changes in menstrual patterns

h. Value-Belief Pattern

• Religious or cultural beliefs influence the selection of treatment.

Nursing Diagnosis for for Disseminated Intravascular Coagulation (DIC)

1) Ineffective Tissue Perfusion r / t disruption of blood circulation.

2) Risk for fluid volume deficit r / t bleeding.

3) Acute pain r / t tissue trauma.

4) Anxiety r / t threat of death from chronic diseases suffered...

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Self-care deficit related to Stroke

Nursing Care Plan for Stroke : Self-care deficit


Definition of Stroke

Stroke is an acute neurological dysfunction caused by impaired blood flow that occur suddenly (within seconds) or raised quickly (within hours) with symptoms and signs corresponding to the focal area disturbed.

Cerebrovascular accident (CVA) also called Stroke is a condition in which the occurrence of neurological deficits caused by decreased blood flow to certain areas of the brain tissue.
Neurological deficits caused by ischemia caused necrotising cells in brain tissue in various areas of the brain.

In the U.S., stroke is the third leading cause of death after heart disease and cancer. This disease can be prevented or minimized by efforts: blood pressure under control, increase awareness of the necessary diet and avoid smoking.


Etiology of Stroke

The occurrence of stroke is caused by the presence of thrombi and emboli that cause the narrowing or occlusion of one of the perfect blood vessels that supply blood to the brain, also if there is bleeding (hemorrhagic). Stroke due to pressure on the walls of blood vessels and arteries spasm, rarely encountered.

1. Thrombosis:

Is the formation of blood clots in blood vessels that can lead to narrowing of the lumen of a blood vessel blockage even happen. Thrombosis is a major cause of cerebral infarction. Two-thirds of strokes are caused by thrombosis due to hypertension and diabetes mellitus both of which can lead to atherosclerosis.

Another factor that can be at risk of thrombosis is an oral contraceptive, coagulation disorders, polycithemia, arteritis, chronic hypoxia, and dehydration. Thrombosis occurs as a result of the formation of atheroma thus narrowing the lumen of blood vessels. Thrombus causing hypoperfusion, infarction and ischemia.

At first occurred paresis (decrease / reduction in force and limb movement), aphasia (language function disorder), paralysis, impaired consciousness, visual disturbances.

2. Embolism:

Blockage / cerebral artery occlusion by an embolus, which resulted in necrosis and edema in the area supplied by the blood vessel blockage.

Embolism is the second leading cause of stroke. Generally derived from the inner lining of the heart (endothelial) where plaque is formed which is then separated and flowed in the blood circulation. If embolism is walking / running on the smaller blood vessels then place it will clog embolism or vascular branching.
Embolism associated with disease / heart problems, namely atrial fibrillation, cardiac infarction, infective endocarditis, rheumatic heart disease, and atrial septal defect. Another cause is not often that air embolism, fat embolism due to fracture femor, amniotic fluid after delivery, and the presence of a tumor.

The attack is sudden. The patient is fully conscious, although patients also feel headache. Prognosis depends location of the blood vessel blockage.

3. Intracerebral hemorrhage:

Bleeding in the brain caused by the rupture of a blood vessel. Intracerebral hemorrhage is usually caused by the presence of hypertension. Another cause is a brain tumor, trauma, thrombolytic treatment, and aneurysm rupture.
Hypertension and atherosclerosis cause degenerative change in the artery walls, causing rupture and hemorrhage. Blood mass will suppress brain tissue. This pressure causes the brain tissue of urgency and decreased blood flow to the brain due to ischemia and infarction.

The area that is often experienced intracerebral hemorrhage putamen and the internal capsule (50%), thalamus, brain hemisper, and pons. Clients will experience a severe headache, nausea and vomiting, loss of ability to walk, dysphagia, eye movement disorders. Bleeding in the post is very dangerous because it is part of the basic life functions. Pons can lead to bleeding in hemiplegia, coma, hyperthermia, and subsequently died.

The prognosis is very bad intracerebral hemorrhage: 70% of patients died due to intracerebral hemorrhage.

4. Subarachnoid hemorrhage:

Caused by the aneurysm, vascular abnormalities, trauma, and hypertension. Aneurysms often occur in patients with atherosclerosis, trauma, hypertension, or vascular abnormalities that are usually congenital bleeding can also be caused by anticoagulant treatment, treatment trhrombolitik, and symphatomimetic.

Bleeding that occurs suppress arachnoid space and cause headache, dizziness, loss of consciousness, nausea, vomiting, fever, pain in the neck and back, paralysis, coma, and later died.


Prevention of Stroke

Primary prevention is to avoid the risk of public health education. Maintain body weight and cholesterol within normal limits, and avoid smoking or using oral contraceptives. Treatment / control diabetes, hypertension and heart disease.

Provide information to clients in connection with the illness with strokes. If already had a stroke, in this situation the goal is to prevent the occurrence of complications with respect to stroke and myocardial wider in the future. In the event of immobility will increase the risk of injury in connection with paralysis and aspiration of the airway. Further Prevention is monitoring the risk factors that can be identified.


Nursing Diagnosis for Stroke : Self-care deficit related to decrease in strength and endurance.

Goal:

Patients can help themselves according to their needs, and be able to express their needs.

Intervention:

1. Assess the capability and level of deficiency to perform day-to-day needs.
2. Maintain support, with a strong attitude.
3. Give positive feedback for any thing done or success.
4. Avoid doing something for patients to do their own patients, but provide assistance as needed

Rational:

1. Assist in anticipating / planning meeting individual needs.
2. Patients will require empathy, care giver to know that will help patients consistently.
3. Increase feelings of self meaning.
4. The patient may be very frightened and very dependent.

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Management and Nursing Care Plan for Dementia

Definition of Dementia

Dementia can be defined as cognitive and memory disorders that can affect daily activities. People with dementia often show some disturbances and changes in daily behavior (behavioral symptoms) that interfere with (disruptive) or do not disturb (non-disruptive) (Volicer, L., Hurley, AC, Mahoney, E. 1998). Grayson (2004) states that dementia is not just ordinary disease, but rather a collection of symptoms caused by multiple diseases or conditions resulting in changes in personality and behavior.


Causes of Dementia


Causes of dementia according to Nugroho (2008) can be classified into 3 major categories:

1. Syndrome dementia with disease essentially unknown etiology, often not found in this class of cerebral atrophy, abnormalities may be present in sub-cellular or biochemical level on enzyme systems, or on the metabolism such as those found in Alzheimer's disease and senile dementia.

2. Syndrome dementia with known etiology but can not be treated,
The main cause in this class include:

• Spinocerebellar degeneration disease.
• Subacute sclerosing leukoencephalitis (van Bogaert).
• Huntington's chorea.
• Creutzfeldt-Jakob disease, etc.

3. Syndrome dementia by etiology of the disease that can be treated, in this class include:
Cerebrovascular disease.

• Metabolic diseases.
• Nutrition disorder.
• Due to chronic intoxication.
• Communicating hydrocephalus.

Dementia (senility) is a severe cognitive decline such that it interferes with activities of daily living and social activities. Cognitive decline in dementia usually begins with the deterioration of memory or memory (forgetful). Dementia mainly caused by Alzheimer's disease is closely related to old age. Alzheimer's disease causes 60% of senility or dementia and is expected to continue.

The classic symptoms of Alzheimer's disease dementia is memory loss happens gradually, including difficulty finding the right word or mention, is not able to recognize the object, forgetting how to use plain and simple objects, such as pencils, forgot to turn off the stove, close the window or close the door, the mood and personality may change, agitation, trouble with memory, and made ​​a bad decision can lead to unusual behavior.

These symptoms are very varied and individual. Gradually the symptoms of Alzheimer's disease may occur in a different time, could be faster or slower. The symptoms are not always an Alzheimer's disease, but if the symptoms lasted more frequent and real, to consider the possibility of Alzheimer's disease (Nugroho, 2008).



Signs and Symptoms of Dementia

In general, signs and symptoms of dementia are as follows:

1. Decline in memory that continues to happen. In patients with dementia, "forget" become a part of daily life that can not be separated.
2. Impaired orientation of time and place, for example: forget the day, week, month, year, where people with dementia are.
3. The decline and inability to arrange words into correct sentences, using words that are not appropriate for a condition, repeat the word or the same story many times.
4. Excessive expression, for example, excessive crying when she saw a television drama, furious at small mistakes committed by others, fear and nervousness that is not grounded. People with dementia often do not understand why these feelings arise.
5. The change of behavior, such as: indifferent, withdrawn and anxious.
6. The whole range of cognitive function is damaged.
7. Originally impaired short-term memory.
8. Personality and behavioral disorders, mood swings.
9. Motors and focal neurologic deficits.
10. Irritability, hostility, agitation and seizures.
11. Psychotic Disorders: hallucinations, illusions, delusions and paranoia.
12. Aphasia, apraxia, agnosia and.
13. ADL (Activities of Daily Living) difficult.
14. Difficult to regulate the use of finances.
15. Not be able to go home when traveling.
16. Forgot to put the important stuff.

Patient Examination

1. Patients routine laboratory examination.
Laboratory tests are only done once a clinical diagnosis of dementia is made to help search the etiology of dementia, especially in reversible dementia, although 50% of people with dementia is Alzheimer's dementia with normal laboratory results, laboratory tests should be performed routinely. Laboratory tests are routinely done include: complete blood count, urinalysis, serum electrolytes, blood calcium, urea, liver function, thyroid hormone, folic acid levels.

2. Imaging
Computed Tomography (CT) scan and MRI (magnetic resonance imaging) has become a routine examination in the examination even if the results are still questionable dementia.

3. Examination of EEG
Electroencephalogram (EEG) does not provide specific features and in most EEG was normal. In the advanced stages of Alzheimer's can illustrate diffuse slowing, and periodic complexes.

4. Examination of cerebrospinal fluid
Lumbar puncture is indicated when clinically encountered acute onset dementia, persons with immunosuppressants, meninges and heat stimuli encountered, atypical presentations of dementia, normotensive hydrocephalus, syphilis test (+), meningeal stinger on CT scans.


Management for Dementia

Psychosocial therapy

Deterioration in mental status has a significant meaning in patients with dementia. The desire to continue living depends on the memory. Short-term memory is lost before the loss of long-term memory in most cases of dementia, and many patients typically experience distress as a result of thinking about how they use more memory function in addition to thinking about the disease being experienced. The identity of the patient has faded over the course of the disease, and they can only use a little bit and getting his memory. Emotional reactions ranging from severe depression to kecemasanyang and catastrophic terrorism is rooted in the realization that understanding itself (sense of self) disappeared.

Patients usually will benefit from supportive psychotherapy and educational so that they can understand the journey and the nature of the illness. They can also get support in her grief and acceptance of worsening disability and attention to the problems of self-esteem. Many functions are still intact can be maximized by helping patients identify activities that can still be doing. A psychodynamic approach to the defect in the function of the ego and the limitations of cognitive function can also be beneficial. The doctor can help the patient to find a way of "peace" with defects ego functions, such as saving a calendar for a patient with a problem orientation, create a schedule to help organize the structure of their activities, and make notes to memory problems.

Psychodynamic interventions involving the patient's family can be very helpful. It helps patients to fight feelings of guilt, sadness, anger, and despair as he slowly felt shunned by the family.

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Nursing Care Plan for Impaired Respiratory Function

Nursing process in patients with Impaired Respiratory Function using measures ranging from assessment, nursing diagnosis, intervention, implementation and evaluation, thus enabling nursing care provided to clients can be optimized.

Assessment

General Assessment of the Respiratory System

The assessment process should be highly individualized nursing (according to the client's problems and needs of the moment). In reviewing the client's respiratory status, the nurse can conduct an interview and a physical examination to maximize the data collected without having to add client respiratory distress. Because the body is dependent on the respiratory system contain important aspect in evaluating the health of the client. Respiratory system primarily serves to maintain the exchange of oxygen and carbon dioxide in the lungs and tissues as well as to regulate acid-base balance, any change in the system will be used effects other systems in the body. In respiratory disease, pulmonary status change occurs slowly, allowing the client to adapt to hypoxia. However, changes such as pneumothorax aspiration, hypoxia that occurs suddenly and the body does not have time to adapt, so as to cause death.


Health History

Health history begins with collecting data on biography, which includes name, age, gender, and the client's life situation. Demographic data are usually recorded on the assessment form which have hospitals or clinics. Note the biological age of the client and compare the performances. Does the client seem appropriate for age, disorders such as lung cancer and chronic lung disease, the client looks older than age. Respiratory history contains information about the client's current condition and previous respiratory problems. Interview clients and families and focus it on the main clinical manifestations of the complaint, the events that led to the current state, past medical history, family history, psychosocial history. Share your questions with a simple, using short sentences that are easy to understand. Where appropriate repeat questions to clarify any questions that have been understandable. Collect a complete history of respiratory conditions conformed to the client.


Main complaint

The main complaint was collected to establish priority nursing interventions, and to assess understanding of the client's current health condition. Common complaints include dipsnea respiratory diseases, cough, sputum formation, hemoptysis, wheezing and chest pain. Focus on manifestations and prioritize questions to get an analysis of symptoms.


Past Medical History

Past medical history provides information about the client and family. Assess the client's clinical conditions such as cough, dyspnea, sputum and wheezing formation, because this condition gives hints about a new problem. In addition to collecting data on childhood immunization, ask the client about the incidence of tuberculosis, influenza, asthma, pneumonia and upper respiratory infection frequency after lower respiratory tract infections, fakator examine factors that affect the baby at the time such as cystic fibrosis, premature birth, the problems associated with the disorder obstructive pulmonary disease, restrictive. Ask clients whether they have been admitted to the hospital, ask when it happened, and obtained medical treatment when it's time. Get information about injuries nose mouth, throat or chest before (such as blunt trauma, fractures of the ribs, thoracic trauma). And important information about free drugs ever consumed.


Psychosocial History

Get information about the psychosocial aspects of client which includes occupation, geographical location, exercise habits, nutrition. Identify all environmental agents that may affect the client, and the work environment and habits.
Ask about the conditions of life of the client, who lives one house number, review the environmental hazards in crowded conditions, and poor circulation. Gather how long smoking history, and how the number of cigarettes consumed , also ask about the use of alcohol, lung ciliary movement is slowed by alcohol so it will reduce the clearance of mucus from the lungs. Ask if client activity tolerance decreased or stabilized, ask the client to describe how to walk, light housework that can be tolerated by the client or vice versa. Maintain a nutritious diet for clients with chronic respiratory disease. Chronic diseases that result in decreased lung capacity lungs work harder. Addition workload requires high calorie and nutrition and if not met will cause weight loss. Clients become secondary to medication anorexia and fatigue. Assess nutrient inputs during the last 24 hours, ask the client to remember the pattern of nutrient inputs during the last week.


Physical Assessment

Physical assessment is done after collecting medical history, use techniques of inspection, palpation, percussion, auscultation. The success of the examination requires nurses to master the posterior thoracic landmarks, lateral, anterior. Use these landmarks to locate under the thoracic organs, especially the lobe of the lung, heart and major blood vessels. Compare one side to the other. Palpation, percussion, auscultation performed backward from the front or from the side of the chest to the other side of the thorax, so that the results obtained are continuous with the other parts to make a comparison. Conditions and skin color observed during the inspection (pale, blue, red). Assess the client's level of awareness and orient the client during the client checks to determine the adequacy of gas exchange.



Nursing Diagnosis

1. Impaired gas exchange related to decreased lung expansion, the presence of pulmonary secretions, inadequate oxygen intake.

2. Ineffective Airway Clearance related to impaired cough, incision pain, decreased level of consciousness.

3. Ineffective Breathing Pattern related to immobilization, depression of ventilation, use of narcotics, neuromuscular damage, airway obstruction.

4. Decreased cardiac output related to irregular heart rhythms, rapid heartbeat.

5. Risk for infection related to static lung secretions.

6. Activity Intolerance which relate to: weakness, inadequate nutrition, fatigue.



Planning

Clients who suffered damage oxygenation, requiring nursing care plan is intended to meet the needs of the actual oxygenation and any potential client. Nurses identify specific end result of care provided. The plan includes one or more client-centered targets the following:

1. Maintain airway patency.
2. Maintain and sustain and improve lung expansion.
3. Capable of removing the pulmonary excretion.
4. Achieve an increase in activity tolerance.
5. Maintained or increased tissue oxygenation.
6. Cardiopulmonary function improved and maintained.

Implementation

Nursing interventions to improve oxygenation and maintain the domain covered by the nursing administration and monitoring therapeutic interventions and programs. This includes independent nursing actions such as behavioral health promotion and prevention, setting position, coughing techniques, and collaborative interventions such as oxygen therapy, lung inflation techniques, hydration, chest physiotherapy, and medicine.

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Impaired Physical Mobility - Nursing Care Plan

Nursing Diagnosis for Impaired Physical Mobility

Musculoskeletal System:

1. Risk for Injury (fall when ambulation)
related to:

• limited endurance.
• a decrease in muscle strength.
• stiffness and joint pain.
• orthostatic hypotension.

2. Impaired Physical Mobility (individuals have limitations on the ability to physically move independently)
related to:

• decreased range of motion.
• bed rest.
• a decrease in muscle strength.
• pain or discomfort.

characteristics:

• Not able to move in bed and the environment, not able to move or ambulation.
• Limitations on the movement of the joints.
• Decreased muscle strength and control of the movement of which is restricted.

Cardiovascular System

1. Activity Intolerance
related to:

• long-term bedrest,
• general weakness,
• imbalance between demand and supply of oxygen.

2. Ineffective Tissue perfusion
related to:

• disorders of blood flow through the vein.
• edema.

Respiratory System

1. Ineffective breathing pattern
related to:

• decrease in lung expansion.
• chest muscle atrophy.
• administration of depressant agents (analgesics, sedatives).

2. Impaired gas exchange
related to:

• Ineffective breathing pattern.
• decline in lung development.
• buildup of lung secretions.

3. Ineffective airway clearance
related to:

• stasis of pulmonary secretions.
• imprecision body position.

Metabolic and Nutritional Systems

1. Imbalanced Nutrition Less Than Body Requirements
related to:

• intake is inadequate.
• catabolism of muscle mass.

2. Imbalanced Nutrition More than Body Requirements
related to:

• imbalance between intake with energy expenditure.

Urinary System

1. Risk for infection: urinary
related to:

• stasis of urine,
• obstruction of urine flow.

 Elimination System

1. Constipation
related to:

• decrease in physical activity,
• lack of privacy is maintained,
• inadequate diet.

Integumentary System

1. Impaired skin integrity
relate to:

• Limitations mobilization.
• Skin surface pressure.
• Frictional forces on the surface of the skin ..

Planning

Musculoskeletal system :

• Muskuloskeltal maintain normal function.
• Normal ROM in all joints.
• Normal strength and muscle mass.
• Actively participate in the activities.

Intervention:

• Create a workout schedule ROM: active, passive and isotonic.
• Encourage active participation remedy selfcare activities.
• Bodyaligment good position.
• Ambulation aids clients if they can or standing on the side of the bed.

Cardiovascular system

• Minimal cardiovascular disorders, characterized by: a standard backflow; adequate vein (no edema, pain, inflammation, venous distention, skin perubahn)

Intervention:

• Monitor vital signs.
• Teach clients how and when should Valsalva maneuver.
• Wear tights if possible.
• Elevate the legs about 20 minutes every day.
• Assess skin in depressed areas.
• View and add also the musculoskeletal system interventions.

Respiratory system

• Maintain normal respiratory function, characterized by clean breath sounds during auscultation, normal chest expansion, no chest pain, fever, chest muscle movement embolism and atelectasis.

Intervention:

• Assess breath sounds and chest expansion every 8 hours.
• Teach clients effective deep breathing and coughing.
• Change the position every 2 hours, and ambulation if possible and place it on a chair.
• Diagfragma abdominal breathing exercises.

Elimination System

• Normal elimination pattern marked no less urine output 1500 ml, urine specific gravity from 1 to 1.025 acidic urine. There is no sign of retention / urinary infection.
• Shaped and soft stool, bowel movement over 2-3 days.

Intervention:

• Monitor the color, density, total acidity of urine, feces color and characteristics, frequency of defecation.
• Diet: increase in protein, calories, fiber.
• Vitamin and mineral supplements.
• Parenteral and enteral supplements.
• Early ambulation and ROM exercises.

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Nursing Care Plan for Impaired Oxygenation

Impaired Oxygenation


Assessment

1. Patient Data

• Name:
• Address:
• Age:
• Gender:
• Level of education:

2. Medical history

• Main complaints: cough, chest pain, increased sputum production, hemoptysis, shortness of breath.
• Family history: a family disease, hereditary diseases and allergies.
• Social history: smoking, work, recreation, environmental conditions, factors allergen.
• The state of the environment: a rundown, marshes, big cities, habits: smoking, activity.

Physical Examination

• Cough: is there any pain when coughing, sputum, shortness of coughing.
• Type cough: is productive, non-productive, continuous.
• When did the cough arises: morning or during activity.
• Sputum: color, odor, consistency: thick / liquid, the amount of blood and frothy.
• Dyspnoea (difficulty breathing): when it arises, the tolerance level of the client's activities.
• Hemoptysis: anytime, anything originators.
• Chest pain: when there is pain, whether the rhythm of breathing.
• Wheezing: sound arising from the air passing through a small channel.
• Skin color: peripheral or central cyanosis.
• Facial edema: usually due to an infection and swelling of the sinuses.
• Chest shape: bird chest, since when did it start.
• Musculoskeletal disorders: is there any use of accessory muscles, weakness, muscle pain.
• Clubbing of nail: Abnormalities of the nails.
• Bad breath: spending waste products of metabolism, kind of smelly breath, acetone, urea and alcohol.
• Breathing pattern: (Neunatus: 30 - 60x/menit; Baby: 44x / min; Children: 20 - 25x / min; adult: 15 - 20x / min), tachypnea, hyperventilation, Kussmaul, cheyne stokes, biot.
• Tactile fremitus: to increase the consolidation and decreased in pneumothorax and pleural effusion.

Physical Examination (Head to Toe)

a. Inspection

• Chest examination starts from the posterior thorax, the client in a sitting position.
• Chest observed by comparing one side to the other.
• Actions carried out from the top (apex) to the bottom.
• Inspection of the posterior thorax and condition the skin color, scars, lesions, masses, such as spinal disorders: kyphosis, scoliosis and lordosis.
• Record the number, rhythm, respiratory depth, and symmetry of chest movement.
• Observations respiratory type, such as: nasal breathing or diaphragmatic breathing, and use of accessory muscles of breathing.
• Abnormalities in chest shape: Barrel Chest; Funnel Chest (Pectus excavatum); Pigeon Chest (Pectus carinatum); kyphoscoliosis; Kiposis; Scoliosis.
• Observations symmetry of chest movement. Movement disorders or inadequate chest expansion indicate lung or pleural disease.
• Observation of abnormal retractions intercostal spaces during inspiration, which can indicate airway obstruction.

b. Palpation

• Thoracic palpation to determine abnormalities in the review of inspections such as: mass, lesion, swelling.
• Assess also the softness of the skin, especially if the client complains of pain.
• Vocal premitus: chest wall vibrations generated when speaking.

c. Percussion

• Normal Percussive sound: Resonant (Sonor) à resonate, low tone. Generated in normal lung tissue.; À dullness generated above the heart or lungs; Tympany àmusikal, resulting in over air-filled stomach.
• Abnormal Percussive sound: Hiperresonan à resonated lower than the resonant and raised in the abnormal lung filled with air. Flatness à very dullness and therefore a higher tone. Percussion can be heard on the thigh, where the area is completely unbiased network.

d. Auscultation

• Normal breath sounds: Bronchial; Bronchovesikular; Vesicular.
• Additional breath sounds: wheezing; Ronchi; Pleural friction rub; Crackles.

Nursing Diagnosis

1. Ineffective Airway Clearance related to :

• Airway obstruction due to thick secretions or foreign bodies.
• Abdominal pain or chest pain that reduces the movement of the chest.
• Drugs that suppress the cough reflex and respiratory center.
• Inadequate hydration, the formation of thick secretions that.
• Immobilization.
• Chronic lung disease that makes it easy buildup of secretions.

characterized by : abnormal breath sounds, productive or non-productive cough, cyanosis, shortness of breath, changes in breathing patterns.


2. Ineffective Breathing Pattern related to

• Inadequate lung development due to: immobilization, obesity and pain.
• Neuromuscular disorders such as tetraplegia, head trauma, anesthesia drugs.
• Airway obstruction due to acute infection, allergy that causes bronchial spasm or edema.

characterized by: dyspnoea, increased respiratory frequency, shallow breathing, chest retraction, enlargement of the fingers (clubbing fingger), breathing through the mouth, cyanosis, orthopneu, vomiting, lung expansion is not elastic.


3. Impaired gas exchange related to:

• Reduced blood volume due to hemorrhage, dehydration.
• Keidakseimbangan excess electrolytes such as blood potassium.

characterized by: cardiac arrhythmias, unstable td, tachycardia or bradycardia, cyanosis, weak, jugular venous distention, reduced urine, edema various respiratory problems (orthopneu, dyspnoea, shortness of breath, cough).



Nursing Interventions

1. Maintaining the airway open.

• Installation of an artificial airway.
• Deep breathing and coughing exercises effective.
• Good position: Fowler or semi-Fowler.
• Suctioning.
• Bronchodilators drug delivery.

2. Mobilization of pulmonary secretions

• Hydration.
• Humidification.
• Postural drainage.

3. Retain and maintain lung development.

• Breathing exercises.
• Installation of mechanical ventilation.
• Installation of chest tube drainage or chest.

4. Reducing / correcting hypoxia and hypoxia due to the compensation body.

• Giving O2 via nasal cannula, catheter, simple mask, endotracheal tube.

5. Increasing gas transportation and cardiak output.

• CPR

Evaluation

Done by collecting repeated data after implementation and the data is compared to the destination.

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Effective Cough Techniques

Effective Cough Definition

Effective cough is a cough with correct method, where clients can save energy so tired and can not easily remove phlegm fullest. Effective cough techniques are actions taken to clear secretions from the respiratory tract. The goal of an effective cough is to improve lung expansion, mobilization of secretions and prevent the side effects of retention of secretions such as pneumonia, atelectasis and fever. Cough effectively make a positive contribution towards expenditure sputum volume. With effective cough patients become aware of how to put out sputum. Healthy people do not spend sputum; sometimes if there is, the amount is very small so it can not be measured. The amount released is not only determined by the disease that was suffered, but also by the stage of the disease.

The trick is prior to coughing, clients are encouraged to drink warm water with a rationalization to dilute phlegm. After it is advisable for the inspiration. This is done for two times. Then after the third inspiration, encourage clients to cough up firmly.


Effective Cough destination

1. Exercising respiratory muscles in order to perform functions properly.
2. Removing existing seputum sputum or respiratory canals.
3. Coaching clients so accustomed to breathing with a good way.

Benefits of Effective Cough

1. To remove secretions that obstruct the airway.
2. To lighten the complaint during a shortness of breath in heart patients.

Indication of Effective Cough
COPD (chronic obstructive pulmonary disease), emphysema, fibrosis, asthma, chest infection, bedrest or postoperative patients.


How Effective Cough

1. Encourage clients to drink warm water (for easy in spending secretion).
2. Breathe in 4-5 times.
3. On the next pull of the breath hold for 1-2 seconds.
4. Lift shoulders and chest loosened and batukan firmly.
5. Do it four times every cough effective, custom-tailored frequency.
6. Note the condition of the patient.

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