D.0006
Risiko Aspirasi
Kategori
: Fisiologis
Subkategori : Respirasi
Definisi
Berisiko mengalami masuknya sekresi gastrointestinal, sekresi orofaring
benda cair atau padat ke dalam saluran trakeobronkhial akibat disfungsi
mekanisme protektif saluran napas.
Faktor Risiko
1. Penurunan tingkat kesadaran
2.
Penurunan refleks muntah dan/atau batuk
3. Gangguan menelan
4. Disfagia
5. Kerusakan mobilitas fisik
6. Peningkatan residu lambung
7. Peningkatan tekanan intragastrik
8. Penurunan motilitas gastrointestinal
9. Sfingter esofagus bawah inkompeten
10. Perlambatan pegosongan lambung
11. Terpasang selang nasogastrik
12. Terpasang trakeostomi atau endotracheal
tube
13. Trauma/pembedahan leher, mulut, dan/atau
wajah
14. Efek agen farmakologis
15. Ketidakmatangan koordinasi menghisap, menelan dan bernapas
Kondisi Klinis Terkait
1. Cedera kepala
2.
Stroke
3. Cedera medula spinalis
4. Guillain barre syndrome
5. Penyakit Parkinson
6. Keracunan obat dan alcohol
7.
Pembesaran uterus
8. Miestenia gravis
9. Fistula trakeoesofagus
10. Striktura esofagus
11. Sklerosis multipel
12. Labiopalatoskizis
13.
Atresia esofagus
14. Laringomalasia
15. Prematuritas
Referensi
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Carpemito-Moyet, L. J. (2010). Nursing
Diagnosis Application to Clinical Practice. 13" Ed. Philadelphia:
Lippincott Williams & Wilkins.
Chapman, L. Durham, R.F. (2010).
Maternal-newborn nursing: The criticalcomponents of nursing care. Philadelphia:
F.A Davis Company.
Doenges, M. E., Moorhouse, M. F., & Mur,
A. C. (2013). Nursing Diagnosis Manual Planning, Individualizing and
Documenting Client Care. 4 Ed. N.,Philadelphia: F. A. Davis Company.
Frola Cavalcante, T., Leite de Araujo, T.,
Pessoa Moreira, R., Gomes Guedes, Venicios de Oliveira Lopes, M., & Martins
da Silva, V. (2013). Clinicalvalidation of the nursing diagnosis Risk for
Aspiration among patients who experienced a cerebrovascular accident. Revista
Latino-Americana De Enfermagem (RLAE), 250-258.
Harrison, E.A. (2011), Neonatal respiratory
care. Ontario: Jones and Barlett Publisher.
Herdman, T H. & Kamitsuru, S. (2014).
Nursing Diagnosis Definitions andClassification 2015-2017, 10" Ed. Oxford:
Wiley Blackwell.
Sumena, H. (2010). Handbook for
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Wooldridge,Fun Piwat Nasional indonesiaJ.,
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