D.0001
Bersihan Jalan Napas Tidak Efektif
Kategori :Fisiologis
Subkategori :Respirasi
Definisi
Ketidakmampuan membersihkan sekret atau obstruksi jalan napas untuk mempertahankan jalan napas tetap paten.
Penyebab
·
Fisiologis:
1. Spasme jalan napas
2. Hipersekresi jalan napas
3. Disfungsi neuromuskuler
4. Benda asing dalam jalan
napas
5. Adanya jalan napas buatan
6. Sekresi yang tertahan
7. Hiperplasia dinding jalan
napas
8. Proses infeksi
9. Respon alergi
10. Efek agen farmakologis
(mis, anastesi)
· Situasional:
1. Merokok Aktif
2. Merokok pasif
3. Terpajan polutan
Gejala dan Tanda Mayor
· Subjektif
(tidak tersedia)
· Objektif
1. Batuk tidak efektif
2. Tidak mampu batuk
3. Sputum berlebih
4. Mengi, wheezing dan/atau
ronkhi kering
5. Mekonium di jalan
napas(pada neonatus)
Gejala dan Tanda Minor
· Subjektif
1. Dispnea
2. Sulit bicara
3. Ortopnea
· Objektif
1. Gelisah
2. Sianosis
3. Bunyi napas
4. Frekuensi napas berubah
menurun
5. Pola napas berubah
· Kondisi Klinis Terkait
1. Gullian barre syndrome
2. Sklerosis multipel
3. Myasthenia gravis
4. Prosedur diagnostik (mis.
bronkoskopi, transesophageal echocardiography [TEE]
5. Depresi sistem saraf pusat
6. Cedera kepala
7. Stroke
8. Kuadriplegia
9. Sindrom aspirasi mekonium
10. Infeksi saluran napas
Referensi
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Brukwitzki G, Holmgren C & Malbusch RM (1996)
Validation of the defining characteristics of the nursing diagnosis ineffective
airway clearance. Nursing Diagnoses,7, 63-69
Carlson-Catalano J, Lunney M, Paradiso C, Bruno J,
Luise BK, Martin T, Massoni M& Pachter S (1998) Cinical validation of
ineffective breathing pattern, ineffective airway clearance and impaired gas
exchange. Journal of Nursing Scholarship, 30, 243-248
Carperito-Moyet, LJ (2013) Nursing Diagnosis
Application to Clinical Practice, 14th Ed Philadelphia: Lippincott Williams
& Wilkins.
Herdman, T. H. & Kamitsuru, S. (2014), Nursing
Diagnosis Definitions and Classification 2015-2017 10 Ed Oxford. Wiley
Blackwell.
Newbeid, S. A Hinz, M. D., Tiley, D. S., Sridaromont,
K. L., Maramba, P. J. (2012). Cor's Clinical Applications of Nursing Diagnosis
Adult, Child, Women's, Mental Health, Gerontic, and Home Health Considerations.
6 Ed.Philadelphia: F.A. Davis Companny.
Pascoal, L. M., Lopes, M. O., da Silva, V. M.,
Beltrão, B. A., Chaves, D. R., Herdman,
T. H. & Costa, A. S. (2016). Clinical indicators
of ineffective airway clearance in children with acute respiratory infection.
Journal Of Child Health Care For Professionals Working With Children In The
Hospital And Community, 20(3), 324-332. doi:10.1177/1367493515598648
VEC. de Seosa, M. V. de Oliveira Lopes & V. M. da
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