D.0005
Pola Napas Tidak Efektif
Kategori : Fisiologis
Subkategori : Respirasi
Definisi
Inspirasi dan/atau ekspirasi yang tidak memberikan ventilasi adekual
Penyebab
1. Depresi pusat pernapasan
2. Hambatan upaya napas (mis. nyeri saat
bernapas, kelemahan otot pernapasan)
3. Deformitas dinding dada
4. Deformitas
tulang dada
5. Gangguan neuromuskular
6. Gangguan neurologis (mis,
elektroensefalogram (EEG) positif, cedera kepala, ganguan kejang)
7. Imaturitas neurologis
8. Penurunan energi
9.
Obesitas
10. Posisi tubuh yang menghambat ekspansi paru
11. Sindrom hipoventilasi
12. Kerusakan inervasi diafragma (kerusakan
saraf C5 ke atas)
13. Cedera pada medula spinalis
14. Efek agen farmakologis
15. Kecemasan
Gejala dan Tanda Mayor
Subjektif
1. Dispnea
Objektif
1. Penggunaan otot bantu pernapasan
2. Fase ekspirasi memanjang
3. Pola napas abnormal (mis. takipnea,
bradipnea, hiperventilasi, kussmaul, cheyne-stokes)
Gejala dan Tanda Minor
Subjektif
1. Ortopnea
Objektif
1. Pernapasan pursed-lip
2. Pernapasan cuping hidung
3. Diameter thoraks anterior-posterior meningkat
4. Ventilasi semenit menurun
5. Kapasitas vital menurun
6. Tekanan ekspirasi menurun
7. Tekanan inspirasi menurun
8. Ekskursi dada berubah
Kondisi Klinis Terkait
1. Depresi sistem saraf pusat
2. Cedera
kepala
3. Trauma thoraks
4. Gullian barre syndrome
5. Mutiple sclerosis
6. Myasthenia gravis
7. Stroke
8. Kuadriplegia
9. Intoksikasi alkohol
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. Do Canto, D. F., & Almeida, M. A. (2013). [Nursing outcomes for ineffective breathing patterns and impaired spontaneous ventilation in intensive care). Revista Gaúcha De Enfermagem/EENFUFRGS, 34(4), 137-145
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. 14° Ed. Philadelphia Lippincott Williams & Wilkins Coucher, B. (2014). The challenge of diagnosing dyspnea. AACN Advanced CrilicelCare, 25(3), 284-290
Herdman, T H. & Kamitsuru S. (2014)
Nursing Diagnosis Definitions andClassification 2015-2017 10" Ed. Oxford:
Wiley Blackwall,
Newfield, S. A. Hinz M D., Tiley, DS,
Sridaromont, K. L. Maramba, P. J. (2012). Cox's Clinical Applications of
Nursing Diagnosis Adult Child, Women's Mental Health Gerontic, and Home Health
Considerations. 6 End Philadelphia FA Davis Companny
Parshal, M. B. Schwartzstein, R. M., Adams, L,
et al (2011). An official American thoracic society statement update on the
mechanisms, assessment, and management of dyspria American Journal of
Respiratory & Critical CareMedicine, 185(4), 435-452
Zeitoun. 8. S, de Barros, A. L, Michel, J. M.,
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