D.0003
Kategori : Fisiologis
Subkategori : Respirasi
Definisi
Kelebihan atau kekurangan oksigenasi dan/atau
eleminasi karbondioksida pada membran alveolus-kapiler.
Penyebab
1. 1. Ketidakseimbangan ventilasi-perfusi
2. 2. Perubahan membran alveolus-kapiler
Gejala dan Tanda Mayor
Subjektif
1. Dispnea
Objektif
1. 1. PCO2 meningkat/menurun
2. 2. PO2
menurun
3. 3. Takikardia
4. 4. pH arteri meningkat/menurun
5. 5. Bunyi napas tambahan
Gejala dan Tanda Minor
Subjektif
1. 1. Pusing
2. 2. Penglihatan kabur
Objektif
1. 1. Sianosis
2. 2. Diaforesis
3. 3. Gelisah
4. 4. Napas cuping hidung
5. 5. Pola
napas abnormal(cepat/lambat, regular/ireguler,dalam/dangkal)
6. 6. Warna kulit abnormal (mis.pucat, kebiruan)
7. 7. Kesadaran menurun
Kondisi Klinis Terkait
1.
Penyakit paru obstruktif kronis (PPOK)
2. Gagal jantung kongestif
3. Asma
4. Pneumonia
5. Tuberkulosis paru
6. Penyakit membran hialin
7. Asfiksia
8. Persistent pulmonary hypertension
Referensi
Ackley, B. J., Ladwig, G. B., & Makic, M. B. F. (2017). Nursing Diagnosis Handbook, An Evidence-Based Guide to Planning Care. 11 Ed. St. Louis: Elsevier.
Avena, M. J., Pedreira, M. da L.. G., & Gutierrez, M. G. R. de. (2014). Conceptual validation of the defining characteristics of respiratory nursing diagnosis in neonates. Acta Paul Enferm, 27(1), 76-85. http://doi.org/1982-0194201400015.
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, L. J. (2013). Nursing Diagnosis Application to Clinical Practice. 14 Ed. Philadelphia: Lippincott Williams & Wilkins.
Herdman, T. H., & Kamitsuru, S. (2014). Nursing Diagnosis Definitions and Classification 2015-2017 10th Ed. Oxford: Wiley Blackwell.
Newfield, S. A., Hinz, M. D, Scott-Tilley, D., Sridaromont, K. L., & Maramba, P. J. (2012). Cox's Clinical Applications of Nursing Diagnosis. 6 Ed. Philadelphia: F.A. Davis Company.
Sousa, V., Lopes, M., Rocha, D., Pascoal, L, Montoril, M., & de Melo, R. (2008).
Impaired gas exchange: analysis in patients with acute myocardial infarction. Revista Enfermagem UERJ, 16(4), 545-549.
Zeitoun, S. S., Liliane, J., Michel, M., & Ca, A. R. (2007). Clinical validation of the signs and symptoms and the nature of the respiratory nursing diagnosis in patients under invasive mechanical ventilation. Journal of Clinical Nursing, 16, 1417-1426. http://doi.org/10.1111/j.1365-2702.2006. 01632.x
