COLLECTION OF NURSING CARE REPORT INTRODUCTION ASTHMA BRONCHIALE

COLLECTION OF NURSING CARE REPORT INTRODUCTION ASTHMA BRONCHIALE
nursing care (askep) on the client with the disease: in, surgical, children, obstetrics, emergency departments, icu, medical surgery etc.
  REPORT INTRODUCTION ASTHMA BRONKHIALE
1 BACKGROUND Asthma is a disease that can affect children into adulthood with a very scary attack without knowing the time that always brings suffering to patients and asthma can arise due to anxiety, activity strenuous activities, fatigue, lack of sleep, respiratory infections, drugs and allergens. In countries that have advanced research, an estimated 5% - 20% of infants and children suffering from asthma. Whereas in adults and older people on average ranged between 2% - 10%. (Sundaru H., p. 6, 1995). Studies that have been done in some places is estimated to 2-5% suffer from asthma.
The incidence of asthma is influenced by many factors including: patient age, gender, allergies talent, interest, heredity, environmental and psychological factors. Various problems posed on asthma depend on age, occupation and client functions in the family. The high recurrence rate in patients with asthma often have an impact on the patient's psychological and biological. Levels of emotional instability and the tendency to reject the suggestions in an effort to eliminate behaviors that support their health, is one of the psychological response of patients with asthma. In an asthma attack patients have functional limitations in meeting all their basic needs. Thus it is necessary difikirkan about the pattern of nursing care that is able to meet the limited functionality without adding to the burden of emotional clients due to the actions nurses both during the attack, and after the attack so that clients can avoid a recurrence and an optimal functioning.
2 DEFINITION OF ASTHMA BRONKHIALE According Crocket (1997), Bronkhiale Asthma is defined as a disease of the respiratory system that includes inflammation of the airway and bronkhospasme symptoms that are reversible. Asthma bronchiale according to the American Thoracic Society's quoted from Barata Wijaya (1990) is a disease characterized by increased response trachea and bronchi to various stimuli with the manifestation of a widespread narrowing of the airway and rank can change, either spontaneously or as a result of treatment.
3 Pathophysiology 3.1 Pathophysiology of Asthma Bronkhiale allergenic Asthma caused by someone who atopy caused by exposure to allergens. Allergens that enter the body through the respiratory tract, skin, gastrointestinal tract and others will ditangkp by makrofaq who worked as Antigen Presenting Cells (APC). After Alergrn processed in APC cells, and then by the cells of allergen presented to TH cells. Tues APC through release of interleukin I (IL-1) activates TH cells, through release of IL-2 by the activated TH cells, the given signal to B cells into plasma cells proliferate and form Ig-E. Ig-E formed tied mastoit. present in tissues and basophils are present in sirkulasi.Hal was made possible because both these cells have receptors on their surface-E.Sel untuk.Ig eosinophils, makrofaq and platelets also have receptors for the Ig-E but with a weak affinity. People who already have mastoit cells and basophils with Ig-E on the surface are not yet showing symptoms. The person is already considered a new desentisisasi or become vulnerable. When people who are already vulnerable were exposed to two times or more with the same allergen, allergens that enter the body will be bound by the Ig-E which already exist on the surface mastoit and basophils. Ties will cause influk Ca + + into the cell and changes in cells that reduce levels of cAMP. CAMP levels that it would lead to decreased cell degranulation. In the process of degranulation of these cells which was first issued as mediators already contained in the granules (preformed) in the cytoplasm which have biological properties, namely histamine, eosinophil, chemotactic factor-A (ECF-A), neutrophil chemotactic factor (NCF) , Trypase and Kinin.Efek are immediately visible by the mediator is the obstruction of bronchi by histamine. According to the present concept of asthma is an inflammatory disease (inflammatory) airway (Samsuridjal & Bharatawidjaja, 1994; Sundaru, 1996) which accompanied the sensitivity of airway hyper reaction to stimuli or bronchi (Bronchial hyper Responsivnees / BHR). The nature of inflammation in asthma that is the typical signs of airway inflammation accompanied by eosinophil cell infiltration. Hipereaktifitas bronchi bronchi is an easy one shrink (constriction) when exposed to the substance / factor with low levels in most people does not cause any reaction, such as allergens (inhalant, kontaktan), pollution, cigarette smoke / kitchen smells tajan and the other either in the form irutan and non irutan (Sundaru, H. p.. 27.1996). Today it is known that hyper-reactivity of bronchi caused by chronic inflammation of the bronchi. Inflammatory cells especially eosinophils are found in large numbers in the bronchi rinse fluid of patients with chronic asthmatic eosinophilic bronchitis bronkhiale as hyper reactivity associated with severe degrees of hyper-reactivity penyakit.di clinic bronchi can be proved by provocation tests using methacholine or histamine. Based on the foregoing current asthma are clinically considered as a reversible penyakir bronkhospasme, is patofisiologik as a hyper reaction and pathological bronchi as an inflammation of the airways. Bronchi in asthma patients experiencing odema in the mucosa and walls, inflammatory cell infiltration, especially eosinophils and release of ciliated cells that cause vibration cilia and mucus on it so that one of the defense of the airways become no longer functioning. Also found in asthma patients bronkhiale presence of airway obstruction by mucus, especially in the branches of bronchi. As a result of bronkhospasme, mucosal edema and hypersecretion of mucus wall of bronchi and then there is a narrowing of bronchi and branches so that it will cause a sense of tightness, wheezing (whezzing) and a productive cough.
3.2 Non-allergenic Bronkhiale Asthma Pathophysiology Non-allergenic Bronkhiale asthma (intrinsic asthma) is not due to allergen exposure but occurs due to some trigger factors such as upper respiratory infections, exercise or heavy physical activity, as well as psychological stress. Asthma attacks caused by the autonomic nervous disorders, especially disorders of the sympathetic nervous beta adrenergic blockade and alpha adrenergic hiperreaktifitas. Under normal circumstances the beta adrenergic activity is dominated by the alpha adrenergic receptors. In most patients with suspected asthma increased alpha adrenergic activity resulting in constriction bronkho causing shortness of breath. Estimated beta adrenergic receptors found on the enzyme in the cell membrane known as adenyl-cyclase and is also called the second massenger. When the receptor is stimulated, then the enzyme adenyl-cyclase is activated and will produce ATP in the cell becomes 3'5 'AMP cyccyclic. cAMP would then lead to dilatation of the smooth muscles of the bronchi, inhibiting the release of mediators from mastosit / basophils and inhibits secretion of mucous glands. Beta adrenergic receptor blockade due to the alpha adrenergic receptor function is more dominant resulting in bronkho constriction, hyper secretion of mucous glands and mucous glands edema bronchi, causing shortness of breath. This is known as the theory of beta adrenergic blockade. (Baratawidjaja, 1990).
4 FACTORS trigger asthma attacks BRONKHIALE Factors that can cause asthma attacks bronkhiale or often referred to as trigger factors are:
4.1 Allergens Allergens are certain substances when inhaled or ingested can cause asthma attacks, such as house dust, house dust mites (Dermatophagoides pteronissynus), mold spores, cat skin flakes, animal dander, some seafood and so on
4.2 Respiratory Infections Respiratory tract infections, especially by viruses such as influenza is one of the most common trigger factors causing asthma bronkhiale. An estimated two-thirds of adult patients with asthma asthma attack caused by respiratory infections. (Sundaru, 1991).
4.3 Psychological Stress Psychological stress as a cause of asthma but rather as triggers of asthma, because many people who have psychological stress but not be bronkhiale asthmatics. These factors play a role trigger asthma attacks, especially in people who are somewhat unstable personality. It is more prevalent in women and children (Jonah, 1994).
4.4 Exercise / physical activity weight Some people with asthma bronkhiale will get asthma attacks when doing sports or excessive physical activity. Run fast and easiest cycling cause asthma attacks. An asthma attack because of physical activity (Exercise Induced Asthma / EIA) occurs after exercise or physical activity is quite heavy and rarely attacks occur several hours after exercise.
5.4 Drugs Beberapapasien bronkhiale sensitive asthma or allergies to certain drugs such as penicillin, salicylates, beta blockers, codeine, and so on.
4.6 Air Pollution Patients with asthma are very sensitive to air dust, smoke, plant / vehicle, smoke cigarettes, smoke containing combustion products of sulfur dioxide and oxides fotokemikal, as well as a sharp odor.
4.7 Work environment An estimated 2-15% of patients with asthma bronkhiale originators is the work environment (Sundaru H., 1991). Some substances are found in the work place that can trigger asthma attacks as in the following table: LOCATION originator 1). Fur and animal skin flakes 2). Subtilis enzyme 3). Coffee and tea dust 4). Cotton dust 5). Toluene diisocyanate 6). Dust grain and grain
7). Ammonia, sulfur dioxide, hydrochloric acid, chlorine 8). Platinum salts 9). Ampisiln, spiramycin, piperasin. 1). Laboratory animals and livestock 2). Detergent industry 3). Coffee and tea processing 4). The textile industry 5). The plastics industry 6). Bakery and warehouse loading and unloading in wheat and grains 7). Chemical and petroleum industries
8). Purification of Platinum 9). Manufacture of Drugs
4.8 Other In addition to the factors mentioned above, there are still factors that trigger asthma attacks such as the environment and the weather is too humid, too hot, too cold, spices (monosodium glutamate), food preservatives (benzoic acid), yellow dye (tartarazin ). And some things can aggravate asthma attacks such as sinusitis, rhinitis and regurgitation of stomach acid.
5 CLINICAL During an asthma attack, the client is experiencing dyspnea and signs of breathing difficulties. The beginning signs of an attack there is the sensation of constriction of the chest (chest tightness), whezing, non-productive cough, and tachypnea takhikardi. Severity of asthma can be classified into: mild, moderate and severe depending on the symptoms. The scoring system awarded to classify them. Table Keperahan Asthma Assessment (Scoring) Symptoms of Use Bronkhodilator PEFR variability (APE) Awake at night 4 Symptoms every day 3 Symptoms <2 per hariperminggu <Every week or time of exercise 1 There are no attacks for 3 months 0> 4 x / day 1-4 x / day <Every day <Per week not for 3 months> 25% 4 15-25% 3 10-15% 2 60-10% 1 <6% 0
Quoted from Assagaf Mukty H & A, 1995 Maximum scores: 12 Mild asthma: 1-5 Asthma is: 6-8 Severe asthma: 9-12
Variability PEFR: PEFR Highest Price - lowest price PEFR X 100%
     PEFR highest price PEFR: Peak expiratory flow rate APE: peak expiratory flow
6. MEDICAL MANAGEMENT Episodes of acute asthma (asthma attacks) can include medical emergencies. Medical intervention for this episode are the primary aims: 1. Maintain airway by decreasing kepatenan bronkhospasme or cleaning excessive secretions or retained. 2. Maintaining the effectiveness of gas exchange 3. Prevent complications such as acute respiratory failure and status asthmaticus Drugs used include bronkhodilator and anti-inflammatory or both.
 Anti-inflammatory medications include: Ø Corticosteroids Ø Sodium cromolyn Ø Anti-inflammatory other Drugs bronkhodilator: a. Adrenergic: • Epinephrine • Ephedrine • isoproterenol • Beta adrenergic agonists selectively b. Non-adrenergic: • Theophylline • Aminofilin There should also dibeirkan oxygen 2-4 liters / minute.
NURSING MANAGEMENT 7 Assessment: 1. History of Nursing Need to be assessed a history of exposure (exposure) factors that usually trigger asthma attacks bronkhiale. And to ask how the client's ability to avoid the trigger factors, or whether the client already knows some of these trigger factors. 2. Main Complaint Client's main complaint is shortness of breath, after exposure to allergens or other factors that trigger asthma attacks bronkhiale. 3. Physical Examination: a. Respiratory system • Increased frequency of breathing, difficulty breathing, shortening the period of inspiration. • Use of accessory respiratory muscles (retraction sternum, lifting the shoulders when breathing). • Respiratory nostrils. • Presence of wheezing is heard without a stethoscope. • The sound of breathing: whezzing, lengthening expiration. • Cough hard, dry and ultimately productive cough. b. Cardiovascular System • Takhikardia • Tensions rise • Pulsus paradoxus (decrease in blood pressure> 10 mmHg during inspiration) • Cyanosis • Dehydration • diaphoresis c. Psychosocial • Increased anxiety: fear of dying, fear of pain, panic, anxiety 4. Investigations: a. Blood: increased IgE levels and increased eosinophil b. Arterial blood gases: PaO2 decrease and PaCO2 PaCO2 but subsequently increased with the increase in airway pressure c. Pulmonary Physiology: The decline in FEV1 d. Skin test: To determine the type of allergen.
Nursing diagnosis and Intervention Plan: 1. The lack of effectiveness with respect to breathing pattern disorders and anxiety expiratory Objectives: Clients were able to demonstrate normal breathing pattern Marked: a. Decrease in respiratory rate to normal kebatas b. Decreased signs of shortness of breath, and decreased respiratory muscle aids. c. Analysis of blood gases within normal limits d. Vital capacity within normal limits Intervention Plan: a. Review the return and the observation of respiratory frequency, depth of breathing and signs of shortness of breath. b. Monitor the value of blood gas analysis to determine the effectiveness of treatment c. Lay the patient in Fowler's position to minimize chest expansion work. d. Give Oxygen pernasal appropriate physician order. e. Do a collaboration with the medical team for the provision of drugs: • Corticosteroids • Bronkhodilator • Antihistamines
2. The lack of effectiveness of airway clearance related to increased production of secretions. Objectives: Clients will menunjkkan effectiveness of airway / client is able to maintain a patent airway. Marked: a. Decrease whezzing and Ronchi b. The speed and depth of breathing normal c. No dispenia, cyanosis d. Analysis of blood gases within normal limits e. Decrease in dry cough / non-productive Intervention plan: a. Assess breath sounds every hour during an acute episode to assess the adequacy of gas exchange. b. If possible, try to suction c. Monitor color and consistency of sputum from asthma often as a result of upper respiratory tract infection. d. Assess the effectiveness of cough clients, encourage to cough effectively. e. Increase fluid intake to prevent secretions are thick, to restore fluids lost due to rapid respiration. f. Give a humidifier to thin the phlegm. g. If the secretions thick and tough out, do chest physiotherapy: percussion and vibration. h. Give mouth care, every 2-4 hours, to eliminate the unpleasant taste as a result of secretions. i. Do the doctors in the provision expectoran order.
3. Anxiety related to breathing difficulties, fear of suffering, and or fear of recurrent attacks. Objectives: Clients demonstrate a decrease fear and anxiety Marked: a. Relaxed facial expression b. Expressing feelings of anxiety reduced c. Vital signs within normal limits Intervention plan: a. Assess level of anxiety (mild, moderate, severe) b. Kaji habits coping skills c. Provide emotional support: • Stay close to the patient during an acute attack • Anticipate the needs of patients • Provide a calm confidence d. Implement relaxation techniques e. Daily activities are lightweight and simple f. Do not talk when it is severe dyspnea
4 Potential recurrence of asthma attacks occur Objectives: Preventing the recurrence Intervention plan Provide counseling about prevention of asthma attacks, namely: a. Maintaining healthy by eating nutritious food, adequate rest, drink lots, recreation and sport appropriate. b. Maintaining the health of the environment, by cleaning the house, room, bedroom and avoid damp places. c. Avoidance of trigger factors. d. Using anti-asthma drugs. Peraat role here is to teach you how to use anti-asthma medication in accordance with the rules of use. e. Others (Meditation).
8 CONCLUSION Asthma caused by several factors trigger the attacks are very scary and tends to result in kekambuhan.Keadaan This raises some of the impacts include: 1. Emotional instability. 2. Healthy behaviors that decrease. 3. Limitations of the body functions. In this case the nurse has a very important role to overcome and prevent asthma attacks. Nursing care provided will help clients meet their basic needs and avoid the recurrence so that it can function optimally.
REFERENCES
Anes, SW. (1998). Essentials of Adult Health Nursing. Menlo Park. California.
Baratawidjaja, G. K. (1990). Asthma Bronkhiale.Dalam Soeparman, Medicine Volume II. Faculty of medicine. Jakarta.
Black. JM and Esther MJ (1997). Medical Surgical Nursing.Vol. 2, W. B. Saunders Company. Philadelphia.
Engram, B. (1998). Medical Surgical Nursing Care Plans. Vol 1. EGC. Jakarta.
Fax, SI and Graw, M (1999). Human Physiology. Hill Companies. Nort America.
Gibson, JM. (1998). Modern microbiology and pathology for nurses. EGC. Jakarta.
Kaliner, MA. (1991). Astma its Pathology and Treatment. Vol. 49, National Institutes of Health Bethesda, Maryland.
Kontaraf, J. (1992). Sports Health Resources. Adventist. Bandung.
Sundaru H. (1995). Asthma: What and How of Treatment. Faculty of medicine. Jakarta.













NURSING CARE CLIENTS WITH ASTHMA
DEFINITIONS Diseases of the bronchi with the characteristics of bronchospasm (Black, 1997).
Etiology and Risk Factors Environmental factors Virus infection Allergens pollutan Factor of the (predisposing) Stress, laughing, crying Exercise (exercise) Changes in temperature Strong odors
Pathophysiology Asthma is a chronic inflammatory process that causes mucosal edema, mucus secretion, inflammation of the respiratory tract. When someone with asthma exposed to extrinsic allergens and irritants (such as dust, pollen, tobacco smoke, mold, drugs, food), respiratory tract becomes inflamed, causing shortness of breath, shortness of breath, wheezing daqn. The initial clinical manifestations (early phase reaction) occurs immediately + 1 hour.
 At the time of client contact with the allergen, IgE produced by B lymphocytes IgE antibodies attach to mast cells and basophils in the bronchial wall. Mast cells release chemical mediators of inflammation such as histamine, bradykinin, prosraglandin and SRS-A (slow reacting subsctance of anaphylaxis). This substance causes dilatation of capillaries that cause edema in the respiratory tract as an attempt to dilute the allergen and rid it of the respiratory tract.
 It may also cause constriction of the airways to close the airway to prevent inhalation of allergen more. On some clients with asthma experienced a late reaction. Although the symptoms in this phase is the same as the initial symptoms, the symptoms do not appear until 2-8 hours after exposure to allergens and may for many hours or even 1 day. In the second phase, the release of chemical mediators cause airway responsiveness. Although in the late phase reaction, mediators pulled the inflamed cells of the other and cause obstruction and persistent inflammation. This chronic inflammation that produces hiperresponsif from the respiratory tract. This leads to the next episode where the response is not only the specific antigen but also stimulate exertion or respiratory clinical manifestations may occur so that an increase in frequency and severity.
 Alpha and beta adrenergic receptors on Sympathetic nervous system found in the bronchus. This leads to bronchoconstriction. Conversely stimulation of beta adrenergic receptors causes bronchodilation. AMP to balance the two receptors. Some theories suggest that asthma may be deficient in adrenergic stimulation. If clients have an asthma attack and no treatment is near, the attack can sometimes be reduced by breathing lips. Caffeine can also be used to stop an asthma attack, but its effectiveness has not been proven.
Clinical manifestations 1. Dyspnea 2. The use of accessory muscles 3. Cyanosis 4. Especially when expiratory wheezing 5. Cough
Diagnostic Examination Spirometer: FR, FEV1, and FVC decreased
         Residual capacity, TLC, residual volume increases Pulse oximetry: a low oxygen saturation Blood Gas Analysis (AGD / BGA) changed during the attack.
Management Emergency Care Kepatenan maintain the airway by reducing bronchospasm and wash the excess production secret. Maintain effective gas exchange. Prevent complications such as acute respiratory failure and status asthmaticus. Beta-adrenergic inhalers Beta-adrenergic receptor is a bronchodilator that stimulates beta-adrenergic and widen the airway. If asthma is not reduced given atropine sulfate nebulizer. Theophyline IV or IV steroids. Atropine is an anticholinergic and block the effects of the parasympathetic system. When the vagus terstimuli, increased bronchial smooth muscle tone. Theophylline is relaxan smooth muscle. While steroids prevent mast cells from damage, thereby reducing edema and spasm. If this treatment does not reduce symptoms, advised clients admitted to hospital for further treatment.
Medical Management Bronchial dilator Steroids Oxygen if PaO2 below 60 mmHg Monitor the clinical manifestations of increased anxiety, increased work of breathing, and an indication of fatigue. Endotracheal intubation and mechanical ventilation may be required Sedation (paralytic agents) is required to blunt respiratory effort and prevent trapped air and increase the pressure further. Status asthmaticus treated with IV corticosteroids and administration of beta-adrenergic inhalers to avoid intubation and mechanical ventilation.
After an acute asthma attack is resolved, the client is assessed to determine the trigger event or factor originator and trained in self-care activities. Steroids are usually terminated for cause adrenal suppression due to steroid treatment.
Penatalaksanan Nursing Assess clinical signs of respiratory distress Emergency care if there is respiratory distress Verify whether the client has a history of heart disease, since beta-adrenergic receptors can lead to tachycardia and stress on the heart. Review a history of asthma Assess the client to ensure / determine if there are patterns to help identify the manifestation trigger asthma symptoms. If the trigger can be identified extrinsic factors are likely to reduce / avoid those factors. Example: if the client is allergic to smoke, the smoke can be avoided. Ask about current treatments, especially for treating other diseases. Some clients are less cautious in taking drugs to reduce bronchospasm. Example: Propranolol (beta blockers) are prescribed for hypertension may cause bronchospasm. Psychosocial. Ask the client's ability to cope with asthma and adaptation to disease recording. Rejection of the disease can interfere with early treatment. It is important to ascertain whether the client is able to overcome the disease. Detection of whether the client is experiencing an increase in the number of stressors. Lifestyle full of stress can make asthma symptoms worse. Assess the family's behavior. Families can be the greatest support and assist clients in recognizing early symptoms. Conversely the absence of family support led to denial and a further source of stress the client. Clients who are newly diagnosed asthma, assessed on the home and work environment that can trigger symptoms of asthma clinic. Then the existence of a furry pet, smoke cigarettes etc. that are allergens.

Nursing Diagnosis, Planning and Implementation Ineffective breathing pattern associated with respiratory disorders and anxiety. Respiratory tract spasm and edema causing no air can enter and exit the lungs. Planning: Expected outcomes: Clients can improve breathing pattern characterized by: a. Decrease in RR within normal limits b. Shortness reduced, decreased use of accessory muscles, decreased breathing nostrils. c. Decrease in anxiety d. BGA values ​​returned to normal limits e. SaO2> 95% f. Vital Capacity within the normal range /> 40% Intervention: a. Kaji RR and depth of breathing is more frequent b. Assess breathing pattern of shortness of breath, breathing lips, nostrils, sternal and intercostal retractions. c. BGA and oxygen saturation monitor to ensure effective treatment. d. Position the client Fowler e. Give oxygen as indicated f. Collaboration of bronchodilators and steroids
Ineffective airway clearance related to increased production of secretions and bronchospasm. Excess mucus production and airway spasm causing difficulty maintaining the airway kepatenan Planning: Expected outcomes: Clients have an effective airway clearance is characterized by: a. Wheezing is reduced b. Ronchi is reduced c. Productive cough Intervention: a. Do suction if the airway is dangerous b. Monitor color and consistency of sputum c. Assess client's ability to cough effectively d. Measure the oral fluids to thin secretions and replace fluids lost through rapid breathing e. Postural drainage, percussion and vibration lung and over the position more frequently if the viscous and difficult secret excluded. f. Give oral care every 2-4 hours to remove the smell of secretions
Impaired gas exchange related to the trapped air (water tripping) If air is trapped in the alveoli, it will cause hypoxia. Planning: Criteria Results: Client has adequate gas exchange is characterized by: a. Wheezing is reduced b. Ronchi is reduced c. Pa O2> 60 mmHg d. PaCO2 (partial pressure of arterial carbon dioxide) <45 mmHg e. PH 7:35 to 7:45 f. There was no cyanosis g. Dry cough is reduced, the client can cough effectively
Intervention: a. Assess lung sounds every hour during an acute episode to ensure adequate gas exchange. b. Assess the skin and mucous membrane color of cyanosis. Remember that cyanosis is a manifestation and an indication of serious problems ertukaran gas. c. Pulse oximetry to monitor oxygen saturation. d. Give oxygen if indicated.
Other nursing diagnoses: 1. Activity intolerance 2. Anxious 3. Nutritional Disorders 4. Disturbances in sleep patterns





CHAPTER II REVIEW REFERENCES
A. The basic concept 1. Understanding a. Asthma Bronkiale Bronkiale Asthma is a disease characterized by an excessive response of the trachea and bronchi of different kinds of stimuli, resulting in constriction of the airways that is widespread throughout the lungs and can be changed sepontan degree or after receiving treatment, (Tjen Daniel, 1991). b. Status Astmatikus Status Asthmatikus a severe asthma attack that can not be solved with conventional treatment and is a medical emergency, if not addressed quickly will happen respiratory failure, (Aryanto Suwondo, karnen B. Baratawidjaja, 1995).
Factors Affecting Incidence of Problems a. Anatomy And Physiology Breathing (respiration) is incident from the outside air containing oxygen into the body. And exhaled air contains carbon dioxide (CO2) as the rest of the oxidation out of the body. Sucking is called inspiration and exhale is called expiratory (Lorraine M.wilson, 1995). Broadly speaking, the respiratory tract is divided into two zones, conduction zone starting from the nose, pharynx, larynx, trachea, bronchi, bronchioles and berakir segmentalis the terminal bronchioles. While respiratoris zone starts from the bronchial respiratoris, alveolar ducts and end on yolk alveulus terminalis (NLGYasmin, 1995 and Syaifuddin, 1997). Respiratory tract from nose to bronchioles lined with ciliated mucous membrane. Kerongga When air enters the nose, the air is filtered, warmed and humidified. The third process is the main function of the respiratory mucosa consisting of a multilevel thoracic epiotel, goblet.Permukaan celled ciliated epithelium and coated by a layer of mucus that sisekresi goblet cells and serous glands. Dust particles can be filtered by coarse hairs found in the nostrils. Whereas the fine particles will be trapped in the mucus layer and then coughed or swallowed. Water for the moisture provided by a layer of mucus, while the heat is supplied keudara inspiration comes from the underlying tissue rich with blood pembulu, so that when the air reaches the pharynx is almost free of dust, temperature close to body temperature and kelembapanya reach 100% (Lorraine M. Wilson, 1995) . Air flows from the nose kefaring which is where the intersection between the road and street food respiration. Pharynx can be divided into three parts: nasopharynx, oropharynx and laringofaring. Under the mucous membrane of connective tissue there, there are also several places named follikel lymph adenoid. Next to them there are two left and right tonsils of the pharynx, (Syaifuddin, 1997). Larynx is an air duct and acts as the establishment of sound is in the front part of the pharynx to the height of the cervical vertebrae and into the trachea below (Syaifuddin, 1997). Laryngeal cartilage is a series of rings that are connected by muscles and contains the vocal cords. Among the glottis are vocal cords which is dividing the upper respiratory tract and lower. At the time of swallowing, laryngeal movement upward, like a door closing and the function of the epiglottis on the larynx aditus shaped leaves serve to direct the food into the esophagus, but if the foreign body could still exceed the glottis, the larynx has a function that will help the cough and secretions out objects merngeluarkan of lower respiratory tract, (Larroin MW, 1995). The trachea was formed 16 to 20 rings of cartilage, which is shaped like a horse's hoof with a length of approximately 5 inches (9-11 cm), width 2.5 cm, and between one another cartilage dihubaungkan by fibrous tissue, next to the covered by mucous membranes that vibrate hairy (ciliated cells), which only moves out. Ciliated cells are useful for removing foreign objects that go along with breathing air, and behind made up of connective tissue covered by a layer of smooth muscle and mukusa, (Syaifuddin, 1997). Tracheal bronchus is a continuation of the existing two yamg found at an altitude of thoracic vertebra to the IV and V. While the place where the trachea branches into right and left main bronchus is called Karina. Karina has a lot of nerves and can cause bronchospasm and cough if the cough is stimulated strong. Right main bronchus is shorter, larger and more vertical than the left. Consisting of 6-8 rings, has three branches. Left main bronchus is longer, and smaller, consisting of 9-12 rings as well as having two branches, (Syaifuddin, 1997). Terminal bronchioles are tiny air channels that do not contain alveoli (air sacs) and has a line of 1 mm. Bronchioles are not reinforced by a ring of cartilage, but is surrounded by smooth muscle so that the size, can be changed. Uadara entire channel, from the nose to the terminal bronchioles are called air conduction channels or conduction zone. It contains columnar bronchial epitellium that contain more goblet cells and smooth muscle, including strecch receptor followed by the vagus, (Lorraine M. Wilson, 1995). Once the terminal bronchioles contained acini, which is the functional unit of the lung, where the gas exchange. Acini consist of: respiratoris bronchioles, alveolar ducts and alveolar yolk terminalis which is the final structure of the lung. (Lorraine M. Wilson, 1995). Broadly speaking, respiratory function can be divided into two: gas exchange and acid base balance. Gas exchange function, there are three processes that occur. First of ventilation, the process of moving out of the entry of air through the branches of the bronchial tracheoesophageal to the alveoli so that oxygen and carbon dioxide removed. This movement occurs because of differences in pressure. The air will flow from the pressure to low pressure tianggi. Thoracic volume during inspiration increases because the diaphragm down and ribs lifted. This causes an increase in the volume of intra-pleural pressure menurunan from -4 mm Hg (relative to atmospheric pressure) to be About a-8mmHg. At the same time decreasing the pressure on the intra pulmunal -2 mmHg (relative to atmospheric pressure). The difference in pressure between the airways and causing atmospheric air to flow into the lungs until the airway pressure equal to atmospheric pressure. In intra-expiratory pressure of 1-2 mmHg pulmunal could increase due to the smaller volume of the piston so that air flows out of the lungs, (Lorraine M. Wilson, 1995). The second process is the inclusion of diffusion of oxygen from the alveoli into the capillaries through the alveolar-capillary membrane. This process occurs because the gas flow from place to place tinggai partial pressure lower partialnya pressure. Oxygen in the alveoli has a higher partial pressure of oxygen inside the blood. Higher blood carbon dioxide pressure of the carbon dioxide partialnya dialveoli. As a result of carbon dioxide from the blood flow to the alveoli, (John Gibson, 1995). The third process is a perfusion which is a process of capillary oxygen delivery to tissues via the blood stream transport. Oxygen can masik to the network via two paths: the first is physically dissolved in plasma and berikata chemically with hemoglobin as oxyhemoglobin, while the carbon dioxide transported in blood as bicarbonate, sodium bicarbonate and potassium bicarbonate in the plasma in the red blood cells. One gram of hemoglobin can mengika 1.34 ml of oxygen. Because the average concentration of hemoglobin in the blood of adults by 15 grams, then 20.1 ml of blood oxygen saturation when the total (Sa O2 = 100%), when the oxygenated blood to reach the network. Oxygen flows from the blood into tissue fluid due to the partial pressure of oxygen in the blood is greater than the pressure in the tissue fluid. Of oxygen in the tissue fluid flowing kedalan cells according to their individual needs. While carbon dioxide produced in the tissue fluid into the flow cell. Partial pressure of carbon dioxide in the network is greater than the pressure of carbon dioxide in the blood then flows from the blood into the tissue fluid (Lorraine M. Wilson, 1995). Function sebagain acid-base balance settings: Normal blood pH ranges from 7.35 to 7.45. While humans can live in pH ranges from 7.0 to 7.45. At the elevation of CO2 either because of failure of function and added CO2 production network that is not compensated by the lungs causing changes in blood pH. Respiratoris Acidosis is a condition of retention of CO2 or CO2 produced by a network of more than that released by the lungs. While respiratory alkalosis is a condition in Pa CO 2 decreased as a result hyper ventilation, (Hudak and Gallo, 1997).
b. Pathophysiology An asthma attack caused by an atopy exposed to allergens that exist in everyday environments and form the immunoglobulin E (IgE). Atopy was derived factor. Allergens enter the body through the respiratory tract, skin, and others will be arrested macrophages as antigen presenting cell work (APC). After a role in cell APC processed allergens, the allergen is presented to Th cells. Th cells deliver signals to B cells with dilepaskanya interleukin 2 (IL-2) to be proliferating plasma cells and form the immunoglobulin E (IgE). IgE is formed will be bound by mastosit that exist in the existing network and basophils role in circulation. When this process is terjadai on someone, that person is or has become vulnerable disensitisasi. When people who are already vulnerable were exposed to two times or more with the same allergen, the allergen will be bound by IgE already present in the surface mastoit and basophils. This bond will cause influk Ca + + into the cell and changes within the cell that reduce levels of cAMP. The decrease in cAMP levels cause cell degranulation. Degranulation of these cells will lead to dilepaskanya chemical mediators include: histamine, slow-releasing suptance of anaphylaksis (SRS-A), eosinophilic chomotetik of anaphylacsis factor (ECF-A) and others. This akanmenyebabakan emergence of three main reactions: muscle-contraction of airway smooth muscle either a large or small that will cause bronchospasm, increased capillary permeability that play a role in the occurrence of mucosal edema which adds to the growing airway narrowing, peningkatansekresi glandular mucosa and increased mucus production . Three such reactions cause interference ventilation, uneven distribution of ventilation with pulmonary blood circulation and impaired alveolar gas diffusion level, the consequences would occur hypoxemia, and acidosis hiperkapnea at advanced stages of boiling, (Barbara CL, 1996, Karnen B. 1994, William RS 1995 ) Based on the etiology, asthma can be classified into two types: intrinsic asthma and asthma ektrinsik. Ektrinsik Asthma (atopy) is characterized by allergic reactions to the originator-specific triggers that can be identified such as: mold pollen, dust, animal dander, milk eggs fish medicines and materials to other allergens. Meanwhile, intrinsic asthma (non-atopic) is characterized by non-allergic mechanisms that react to non-specific triggers such as cold air, chemical substances, which are as irritants such as ozone, ether, nitrogen, changing seasons and weather, excessive physical activity, stress mental as well as other intrinsic factors. (Antoni C, 1997 and Tjen Daniel, 1991). Sudden asthma attack can be divided clinically into three stages. The first stage is characterized by periodic coughing and dry. Cough is due to irritation of mucous is thick and clump together. At this stage the edema and swelling of the bronchi. The second stadium was marked by cough with clear mucus and frothy. Clients feel shortness of breath, trying to breathe in, followed by the lengthening expiratory wheezing (wheezing). Clients prefer to sit with his hands placed on the edge of the bed, penberita looked pale, agitated, and began to turn blue skin color around. While the third stadium marked almost no sound of breath because the air flow is small, no coughing, breathing becomes shallow and irregular, high respiratory rhythm due to asphyxia, (Tjen Daniel, 1991).
c. Management Treatment of asthma broadly divided in the treatment of non-pharmacologic and pharmacologic treatment. 1. Coronation non-pharmacologic a) Extension Guidance is aimed at increasing the client's knowledge about asthma disease sehinggan client consciously avoiding trigger factors, as well as using the drug properly and berkonsoltasi the health team. b) Avoidance of trigger factors Clients need to be helped to identify the trigger asthma attacks that exist in the environment, and are taught how to avoid and reduce trigger factors, including adequate fluid intake to the client. c) Physiotherapy Fisioterpi can be used to facilitate the expenditure of mucus. This can be done with postural drainage, percussion and fibrasi chest.
2. Pharmacologic treatment a) beta agonist Aerosol form works very fast diberika spray 3-4 times and the distance between the first and second spray adalan 10 minutes. Which include the drugs are metaproterenol (Alupent, metrapel). b) Methyl Xantin Group methyl xanthine adalan aminophilin and teopilin, the drug is given when a class of beta-agonists did not give satisfactory results. In adults given empatkali 125-200 mg a day. c) Corticosteroids If beta agonists and methyl xanthine does not respond well, should be given corticosteroids. Steroids in aerosol form (beclometason dipropinate) with 800 disis spray four times daily. Because of the long steroids have side effects then that gets long-term steroids should be watched closely. d) cromolyn Cromolyn is an asthma preventer medication, especially children. The dose ranges from 1-2 capsules four times daily.
e) ketotifen Effects of cooperation with cromolyn with a dose of 2 x 1 mg per day. Keuntunganya can be administered orally. f) Iprutropioum bromide (Atroven) Atroven is antikolenergik, given in aerosol form and is a bronchodilator. (Evelin and Joyce L. kee, 1994; Karnen baratawijaja, 1994) 3. Treatment during an attack of status asthmatikus a) Infusion RL: D5 = 3: 1 every 24 hours b) Provision of oxygen 4 liters / minute via nasal cannula c) Aminophilin bolus 5 mg / kg given slowly over 20 minutes dilanjutka Rlatau D5 mentenence drip (20 drops / minute) at a dose of 20 mg / kg bb/24 hours. d) terbutaline 0.25 mg / 6 hours in sub-cutaneous. e) Dexamatason 10-20 mg/6jam intra venous. f) broad spectrum antibiotics. (Guidelines for the management of pulmonary status asthmatikus UPF Dr. Soetomo Hospital Surabaya). Impact of problem a. On the client
    People with asthma should be changed daily lifestyle to avoid trigger factors. This change starts from the environment sanpai with the work environment. On the client with asthma attacks, then a decline in appetite, drinking so that an impact on nutritional status of the client. The rest is disturbed so that clients can cause fatigue. An imbalance between demand and supply of oxygen tolerance in an impact on activity, fatigue quickly exhausted and the inability to meet the ADL. Clients can grow and develop into low self-esteem, feelings of inadequacy, unstable personality, irritability, restlessness and anxiety. Activity limitations, the client is more dependent on others, sometimes the client can not act in accordance with peranya, (Antony C. 1997; Tjen Daniel, 1991). b. In the family
   Seeing the condition of clients with symptoms of asthma and hospitalized, about the causes, prognosis of disease and the success of therapy, will cause anxiety in the family. The need for clients treated dirumahsakit cause loss of response to the family of the deceased. Client role within the family as an economic resource will be disrupted because the client can not come to work and care and hospital costs are not a few would be a burden to the family.
B. Nursing Care Nursing care is a therapeutic process that involves a cooperative relationship between the nurse with the client, family, or community to achieve a degree of health, optimal in providing nursing care dugunakan nursing process method that includes: assessment, diagnosis keperawatanm, planning, implementation and evaluation. 1. Assessment a. Data collection. 1) The identity of the client. Recitation of the name, age, gender danjenis need to review the disease status of asthmatikus. Asthma attacks at an early age implies that it is very likely there atopy status. While the attack at the age of adulthood in non-atopic mingkinkan presence of factors. Address describes the environmental conditions where the client is, can know the likely trigger asthma attacks. Marital status, emotional disturbances arising within the family or the environment is a trigger asthma attacks, work, and the nation should also be paid to detect exposure elergen materials. Another thing that needs to be assessed on: Date MRS, Medical Record Number, and medical diagnosis. (Antony C, 1997; M Amin 1993; karnen B 1994).
2) History of present illness. Clients with asthma attacks come seeking help with symptoms, especially shortness of breath that great and sudden then followed by other symptoms are: Wheezing, use of accessory muscles, fatigue, impaired consciousness, cyanosis and changes in blood pressure. There should also be assessed the initial conditions of the attack. 3) History of past illness. Disease who had suffered in times past such as upper respiratory tract infection, sore throat, tonsillitis, sinusitis, nasal polyps. A history of asthma attack frequency, time, the allergens are suspected of being the originator of the attack and the history of treatment performed to relieve symptoms of asthma (Tjen Daniel, 1991) 4) Family health history. On the client with status attacks asthmatikus need to be assessed on a history of asthma or other allergic diseases in family members because of hypersensitivity in asthma disease is more determined by genetic factors by the environment, (Alsagaf Hood, 1993).
5) History spikososial Emotional disorders are often viewed as one trigger for asthma attacks both disorders were derived from the household, neighborhood until the work environment. A person who had a potentially heavy financial burden that asthma attacks. orphans, relationship disharmony with others to fear can not run a role as before, (Antony Croket, 1997 and Tjen Daniel, 1991).
6) The pattern of health functions a) The pattern of reception and administration of a healthy life Symptoms of asthma can limit people to behave in a normal life with asthma so that the client must change their lifestyles according to the conditions that allow no asthma attack (Antony Crokett; 1997, Tjien Daniel; 1991, Karnen B; 1994) b) Patterns of nutrition and metabolism Needs to be studied include the client's nutritional status, amount, frequency, and the difficulties in meeting their needs. As well as on the client tightness, once a potential shortage in meeting nutritional needs, this is because dipsnea while eating, the rate of metabolism and anxiety experienced by the client, (Hudak and Gallo; 1997).
c) The pattern of elimination Needs to be studied about bowel and bladder habits include colors, shapes, concentration, frequency, number and difficulty in implementing it. d) The pattern of sleep and rest Needs to be studied on how to sleep and how long the client's clients include sleep and rest. And how much due to fatigue experienced by the client. Presence of wheezing, breathlessness and orthopnea may affect sleep and rest patterns of clients, (Antony C.; 1997) e) The pattern of activity and exercise Need to be assessed on daily activities such as sports clients, work and other activities. Physical activity can occur asthma trigger factors known to Exerase Induced Asthma, (Tjien Daniel; 1991) f) The pattern of relationships and roles Symptoms of asthma symptoms severely restricting the client to live a normal life. Clients need to adjust the condition with good client relationships and the role of domestic environment, community or work environment, (Antony C, 1997) g) The pattern of perception and self-concept Needs to be studied about the client's perception tarhadap illness. DAPT inhibits misperception cooperative response to the client. The wrong way of looking at themselves will also be a stressor in the lives of clients. The more stressors that exist on the client's life with asthma increases the likelihood of recurrent asthma attacks. h) The pattern of sensory and kognetif Abnormalities in the patterns of perception and self-concept kognetif will memepengaruhi clients and ultimately affect the number of stressors experienced by the client so the possibility of asthma attacks that berulangpun will be higher.
i) Patterns of sexual reproduction Sexual reproduction is a basic human need, when needs are not met will be a problem in the client's life. This issue will be a stressor that will increase the likelihood of asthma attacks. j) The pattern of stress penangulangan Stress and emotional tension are intrinsic factors trigger asthma attacks it is necessary to review the causes of stress. The frequency and impact on the lives of clients and how countermeasures to stressors, (Tjien Daniel; 1991) k) The pattern of values ​​and beliefs Proximity clients on something he believes the world can increase the strength of the soul to believe the client. Client's belief in God Almighty and on His approach is a constructive method of stress reduction.
7) The physical examination a) general health status Need to be assessed on client awareness, anxiety, restlessness, weakness of the speaking voice, blood pressure pulse, respiratory rate of increase, the use of auxiliary respiratory muscles cyanosis and cough with sticky mucus resting position the client (Laura AT; 1995, Karnen B; 19 983). b) Integumentary Examined the surface of the rough, dry, pigmentation disorders, skin turgor, moisture, peeling or flaking, bleeding, pruritus, enzymes, as well as the former or sign urticaria or dermatitis examine the hairs of the hair color, moisture and dull. (Karnen B; 1994, Laura A. Talbot; 1995). c) The Head. Assessed on head shape, symmetry of protrusion, history of trauma, presence of headaches or dizziness, vertigo or loss of consciousness kelang. (Laura A. Talbot; 1995). d) eyes. A decrease in visual acuity will increase the stress on the client feels. And the history of other eye diseases (Laura A. Talbot; 1995)). e) Nose The presence of respiratory use nostrils, allergic rhinitis and olfactory function (Karnen B.; 1994, Laura A. Talbot; 1995) f) The mouth and larynx Studied the bleeding of the gums. Impaired sense of swallowing and chewing, and pain and tightness in the throat or voice change. (Karnen B.: 1994)). g) Neck Assessed the neck pain, stiffness in pergerakaan, pembesran thyroid and the use of respiratory muscles (Karnen B.; 1994). h) thoracic (1) Inspection Chest in the shape and posture inspection kesemetrisan mainly to an increase in anteroposterior diameter, intercostal muscle retractions, as well as the nature and frequency of respiratory rhythm peranfasan. (Karnen B.; 1994, Laura AT; 1995). (2) Palpation. On palpation in the review of kosimetrisan, expansion and tactile fremitus (Laura AT; 1995). (3) Percussion In the percussion sound was normal until hipersonor obtained while the diaphragm becomes flat and low. (Laura A.T.; 1995). (4) Auscultation. There is an increased vesicular sounds expirasi accompanied by more than 4 seconds or more than 3x inspiration, with the sound of breathing and Wheezing. (B Karnen.; 1994). i) Cardiovascular. Examine an enlarged heart at heart or not, noisy breathing and heart sounds hyperinflasi weakened. Blood pressure and pulse rate increased and the presence of pulsus paradoxus, (Robert P.; 1994, Laura AT; 1995). j) Abdomen. Need to examine the shape, turgor, pain, and signs of infection because it can stimulate the respiratory frequency of asthma attacks, and the presence of constipation due to nutrients (Hudak and Gallo; 1997, Laura AT; 1995). k) extremities. In the review of the edema extremitas, tremors and other signs of infection in extremitas because it can stimulate asthma attacks, (Laura AT; 1995). 8) Investigations. a) Examination spinometri. These checks are performed before and after class adrenergic aerosol bronchodilator. An increase in FEV or FVC by more than 20% indicates a diagnosis of asthma, (Karnen B; 1998). b) brokial provocation test. Done if the internal spinometri examination. Decrease in FEV, by 20% or more after provocation tests and heart rate 80-90% of the maximum rise is considered meaningful if PEFR decreased 10% or more, (Karnen B.; 1998). c) Examination of skin tests. To show the presence of IgE antibodies specific hypersensitivity in the body, (Karnen B.; 1998). d) Laboratory. (1) blood gas analysis. Only in severe asthma attacks did on because there is hypoxemia, hyperkapnea, and respiratory acidosis, (Karnen B.; 1998). (2) Sputum. The existence of very kreola is characteristic for severe Asthma attack, because only a great reaction that causes transudation of adema mukasa, so terlepaslah group of cells - epithelial cells of the will stick. Peawarnaan grams important to see the presence of bacteria, followed by culture and test resistance to multiple antibiotics, (Arjadiono T.; 1995). (3) The cell of eosinophils In patients with status asthmatikus eosinophil cells can reach 1000 - 1500 / mm 3 or extrinsik both Intrinsic asthma, whereas the normal eosinophil cell count between 100-200/mm3. Improvement in lung function with decreased eosinophil cell counts showed the treatment was appropriate, (Arjadiono T.; 1995). (4) Inspection and routine blood chemistry Leukocyte cell count more than 15,000 occurred because of infection. SGOT and SGPT increased due to liver damage caused by hypoxia or hiperkapnea, (Arjadiono T.; 1995). e) Radiology Radiological examination done to rule out the existence of pathological processes such as asthma or complications diparu pneumothorak, pneumomediastinum, atelektosis and others - others, (Karnen B.; 1998). f) Electrocardiogram ECG changes obtained in 50% of patients Asthmatikus status, is due to hypoxemia, changes in pH, pulmunal hypertension and right heart load. Sinus tachycardia - often occurs in asthma. b. Analysis of data The data collected should be analyzed to determine the client's problem. Analysis of data is the intellectual process which involves grouping the data, identify gaps and determine the pattern of the data collected and compare the structure or group of data with standard normal values, interpret the data and ultimately make a conclusion. The results of the analysis is the nursing problem statement.
2. Nursing Diagnosis. Nursing diagnosis is a statement describing the health status or actual or potential problems. Nurses use the nursing process in identifying and synthesizing clinical data and determining nursing interventions to reduce, eliminate or prevent health problems that exist on the client's responsibility, (Lismidar; 1992). Here is a nursing diagnosis that often appears on the client status astmatikus. a. The lack of effectiveness of airway clearance related to increased secretion of thick mucus production and bronchospasm (Lindajual C.; 1995). b. The lack of effectiveness of breathing patterns associated with distended chest wall and respiratory exhaustion due to work, (Hudak and Gallo; 1997). c. Anxiety associated with breathlessness and fear sufokasi. (Lindajual C; 1995). d. Damage to gas exchange associated with CO2 retention, increased secretion, increased work of breathing and the disease process, (Susan Martin Tucker; 1993). e. High risk of impaired nutrition less than body requirements related to the high metabolic rate, dipsnea while eating and anxiety, (Hudak and Gallo; 1997). f. High risk of infection associated with retention of secretions, ineffective cough and immobilization, (Hudak and Gallo; 1997). g. High risk of fatigue associated with CO2 retention hypoxemia, emotion focused on respiratory and sleep apnea, (Hudak and Gallo; 1997). h. High risk disobedience associated with less knowledge about current conditions and self-care home, (Susan Martin Tucker; 1993).
3. Plan After gathering client data, organize data and establish a nursing diagnosis is the next stage of planning. At this stage the nurse's care plan and determine what approach is used to solve client problems. There are three Pase at the planning stage is to determine priorities, set goals and plan of nursing actions, (Lismidar; 1992). Planning of the diagnosis - nursing diagnosis above is as follows: a. The lack of effectiveness of the airway associated with increased production of viscous mucus secretions bronchospasm. 1) Purpose Airway becomes effective. 2) Criteria results (A) determining a comfortable position so as to facilitate an increase in gas exchange. (B) can demonstrate an effective cough (C) may declare a strategy to reduce the viscosity of secretions (D) no additional breath sounds 3) Plan of action (A) Assess color, consistency and amount of sputum (B) Instruct the client on the proper method in controlling cough. (C) Teach the client to reduce the viscosity of secretions (D) Auscultation of lung before and after the action (E) Perform chest physiotherapy with postural drainage techniques, percussion and fibrasi chest. (F) Encourage and or provide oral care 4) Rational (A) Characteristics sputrum can indicate the severity of obstruction (B) uncontrolled coughing ineffective and tiring and frustrating (C) Secretion of thick hard untuyk removed and may result in mucus plugging that can cause atelectasis. (D) Reduction in additional votes after the show the success actions (E) Fisioterpi chest is a strategy to remove secretions. (F) Good oral hygiene increase the sense of healthy and prevent bad breath.
b. The lack of effectiveness of breathing patterns associated with chest wall distention, and fatigue due to increased work of breathing. 1) Purpose Clients will demonstrate effective breathing pattern 2) Criteria results (A) Frequency of effective breathing and improvement in pulmonary gas exchange (B) Stating the factors causing and adaptive ways to overcome these factors 3) Plan of action (A) Monitor frequency, rhythm and depth of breathing (B) Position the client's chest semi-Fowler position (C) Divert the attention of the individual from thinking about the state of anxiety and teaches how to breathe effectively (D) Minimize gastric distention (E) Assess breathing during sleep (F) Reassure the client and give support when dipsnea 4) Rational (A) Tachypnea, irregular rhythms and breathing shallow breaths showed a pattern of ineffective (B) semi-Fowler position will lower the diaphragm so as to provide the development of the pulmonary organs (C) Anxiety can lead to ineffective breathing pattern (D) gastric distension may inhibit contraction of the diaphragm (E) The presence of sleep apnea showed an ineffective breathing pattern (F) Sense of hesitation on the client can inhibit therapeutic communication.
c. Anxiety associated with breathlessness and fear sufokasi. 1) Purpose Asietas reduced or lost. 2) Criteria results (A) The client can describe the anxiety and fikirnya pattern. (B) Munghubungkan increased psychological and physiological comfort. (C) Using an effective coping mechanism in dealing with anxiety. 3) A plan of action. (A) Assess the level of anxiety experienced by the client. (B) Assess the habit of coping skills. (C) Give emotional support for comfort and peace of heart. (D) Implement relaxation techniques. (E) Describe any actions the procedure to be performed. (F) Maintain a rest period that has been planned.
4) Rational. (A) Knowing tinggkat anxiety for ease in planning further action. (B) Assessing coping mechanisms that have been done as well as offering an alternative coping that can be used. (C) Emotional support can strengthen the heart to achieve the same goal. (D) Relaxation is one method to reduce and eliminate anxiety (E) An understanding of the procedure will motivate clients to more cooperative.
d. Damage to gas exchange associated with CO2 retention, increased secretion, increased respiration, and the disease process. 1) Purpose The client will maintain adequate gas exchange and oxygenation. 2) criteria of the results (A) Frequency of breath 16-20 times / minute (B) The frequency of the pulse 60-120 beats / minute (C) normal skin color, no dipnea and GDA within normal limits 3) Plan of action (A) Monitoring respiratory status every 4 hours, the results of GDA, income and output (B) Place the client in semi-Fowler position (C) Provide IV therapy as ordered (D) Provide oxygen via nasal cannula 4 l / mt further adjust the results of PaO2 (E) Provide treatment that has been determined and observe if there are signs - signs of toxicity 4) Rational (A) To identify the indications of progress toward or deviation from the client (B) an upright position allows better lung expansion (C) To allow rapid rehydration and can assess the situation for vascular drug delivery - emergency medicine. (D) The provision of oxygen to reduce muscle load - the respiratory muscles (E) Treatment of bronchial conditions such as to restore the previous state (F) To facilitate breathing and prevent atelectasis.
e. High risk of impaired nutrition less than body requirements related to the high metabolic rate, while eating and anxiety dipsnea 1) Purpose Meeting the nutritional needs are met 2) Criteria results (A) The client spent a portion of food in hospitals (B) No weight loss 3) Plan of action (C) To identify factors that can cause decreased appetite such as vomiting with the finding that a lot of sputum or dipsnea. (D) Encourage clients to oral hygiene at least one hour before meals. (E) Perform the perilstaltik bowel sounds, and palpation to determine the future of the gastrointestinal tract (F) Provide diit TKTP accordance with the provisions (G) Assist the client before a meal break (H) Weigh weight every day 4) Rational (I) Plan of action is selected based on the cause of the problem. (J) With good oral care that will increase your appetite. (K) Determine the existence and condition of the intestines and constipation. (L) Meeting the number of calories needed by the body. (M) Fatigue can menurunakn appetite. (N) indicates the fall in body weight of less nutritional needs.
f. High risk of infection associated with retention of secretions, ineffective cough and immobilization. 1) Purpose Clients do not experience nosocomial infection 2) Criteria results There is no sign - a sign of infection 3) Plan of action (A) Monitor the sign - a sign of infection every 4 hours. (B) Use sterile technique for treatment infusion. or invasive act of others. (C) Maintain a general awareness. (D) Inspection and record the color, consistency and amount of sputum. (E) Provide adequate nutrition (F) Monitor and report white blood cell abnormalities (G) Give antibiotics according to the indication 4) Rational (A) The existence of rubor, tumor, dolor, showed signs of heat - a sign of infection (B) sterile technique break the chain of nosocomial infections (C) Vigilance provide adequate preparation for nurses to take action when there are changes in client's condition. (D) Sputum is a media development of germs. (E) Adequate nutrition provides increased endurance. (F) The cell shows increased white darh possibility of infection. (G) precautions against germs that enter the body.
g. High risk of fatigue-related CO2 Referrals, hypoksemia, emotions are focused on respiratory and sleep apnea. 1) Purpose Clients will be met need a break to maintain the level of waking enegi 2) Criteria results (A) Able to discuss the causes of fatigue (B) The client can sleep and rest according to the needs of the body (C) The client can be relaxed and his face brightened. 3) Plan of action (A) Explain the reasons - because the individual fatigue (B) Avoid disturbances during sleep. (C) Analyze together - the same level of fatigue by using a scale Rhoten (1982). (D) Indentivikasi activity - an important activity and adjust the activity with rest. (E) Teach breathing techniques are effective. (F) Maintain O2 if additional training. (G) Avoid the use of sedatives and hipnotif. 4) Rational (A) Knowledgeable factors that cause it is expected to avoid bias. (B) Sleep is an attempt to restore the conditions which had declined after the activity. (C) Scale Rhoten to know the level of fatigue experienced by the client. (D) Fatigue occurs because of imbalance between the needs of the activities and needs a break. (E) Respiratory assist Unfulfilled O2 dijaringan effective. (F) O 2 is used for the combustion of glucose into energy. (G) Sedatives and hypnotics weaken the muscles of the respiratory muscles in particular.
h. High risk disobedience associated with lack of knowledge about the conditions and self care at home. 1) Purpose Clients able to demonstrate a desire to follow the treatment plan. 2) Criteria results (A) Client able to convey an understanding of the conditions and self care at home (B) Using the tool - the proper respirator 3) Plan of action (A) Help identify factors - factors trigger asthma attacks (B) Teach asthma action to overcome and prevent hospitalization (C) Advise and give alternatives to avoid precipitating factors. (D) Teach and let the client demonstrated breathing exercises. (E) Describe and suggest to avoid infectious diseases. (F) Instruct the client to report when there are changes karakteristrik sputum, increased temperature, cough, shortness of breath or weakness weight gain or swelling in your feet. 4) Rational (A) Knowledgeable made it easy to avoid trigger asthma attacks. (B) Preventive action is an effort will be undertaken to provide comprehensive services. (C) One of the preventive measures is to avoid a client of precipitating factors. (D) Clients with asthma sewring experiencing anxiety resulting in ineffective breathing pattern so need to do breathing exercises. (E) infection is primarily a factor causing respiratory asthma attack. (F) Changes highlighted the need for immediate treatment to avoid complications.
4. Implementation Implementation is an implementation of the planning of nursing by a nurse. Like the stage - another stage in the nursing process, the implementation phase consists of several activities, among others: a. Validation (validation) nursing plan b. Writing / documenting the nursing plan c. Provide nursing care d. Continuing data collection.
5. Evaluation Evaluation is the final step in the nursing process which is a deliberate and continuous activity that involves the client nurses and other health team members The purpose of evaluation is: a. To assess whether the goals in treatment plan is achieved or not b. To conduct the review To be able to assess whether this goal is achieved or can not be proved by the behavior of clients a. The goal is achieved if the client is able to demonstrate the manner in accordance with the statement of purpose at the time or date specified b. The purpose is achieved in part if the client has been able to show the practice, but not entirely in accordance with its intended purpose statement c. The goal is not achieved if the client is unable or unwilling to completely demonstrate the manner specified