Anatomi
2. Physiology
Breathing is an event Definition breath of air from the outside containing oxygen into
the body and blowing air that contains CO2 as the rest of the oxidation out of the
body.
This air sucking is called inspiration and exhaling is called expiration. Lung breathing
Represents the exchange of oxygen and carbon dioxide that occurs in the lungs.
Breathing through the lungs or respiratory external oxygen is taken by mouth and
nose when breathing where oxygen entering through the trachea to the alveoli
associated with blood in the capillaries pulmonary, alveoli separate oxygen from the
blood, O2 penetrate the membrane, drawn by the red blood cells were taken to heart
And from the heart is pumped throughout the body.
For respiration:
A. Taking O2 which is then carried by the blood throughout the body (cells) to burn.
B. Eject CO2 that occurs as a residue from combustion, then carried by blood to the
lungs for disposal (because it is no longer useful by the body).
C. Warm and moisturize the air.
Breathing normally Adults: 16-18 x / mnt Children approx: 24 x / min Babies approx:
30 x / min
Respiratory organs
D. Upper respiratory tract
The nose is the first air channel, has 2 holes, separated by the nasal septum (oil septum)
in which there are feathers that are useful for filtering air, dust, and dirt into the
nostrils.
Faring Is the place of intersection between janaln breath and street food. It is under the
base of the teng korak, behind the ronga of the nose and the front mouth of the neck
bone deer.
Pharynx divided into three parts:
E. The upper part is the same height as the koana called the nesofaring
F. The middle section of the same height denan istmus fausium called orofaring.
G. The lower part of the partition, called the langiofaring.
H. Larynx It is a short channel that connects the pharynx and trachea, and acts as a
sound formation.
I. Lower respiratory tract organs
Trachea is a continuation of the larynx formed by 16 s / d 20 rings consisting of horse-
shaped bones shaped like a horse's hooves. The trakhea length is 9-11 cm and the
back consists of connective tissue lined with smooth muscle.
Bronchial and alveoli The distal end of the trachea divides into the right and left
primary bronchi located within the chest cavity.
The function of the bronchial branching to provide a channel for air between the
trachea and the alveoli. Alveoli amounts to 300-500 million in the lungs, its function
is as the only place of gas exchange between the external environment and blood
flow.
A. The lungs are a body tool consisting mostly of bubbles (bubble of air-alveoli). These
alveolar bubbles are composed of epithelial and endothelial cells. The number of
lung bubbles is approximately 700,000,000 pieces (left and right lung).
Lung capacity:
Total Capacity: The amount of air that can fill the lungs in deep insulation.
Vital capacity: The amount of air that can be expelled after maximum expiration.
Torax
The thoracic cavity consists of the right and left pleural space and the middle part
called the mediastinum. The thorax has an important role in breathing, because of
the elliptical shape of the ribs and the angle of attachment of the spine. Changes in
the size of the thorax is what allows the process of inspiration and expiration.
Parts of the lungs:
Pleura is the outermost part of the lung surrounded by a smooth, slippery or pleural
membrane.
Mediastinum is the part of the wall that divides the thoracic cavity into 2 parts
The lobe is the lung part divided into the left lobe consisting of the lower and middle
lobes and the upper and lower lobes
Bronchial and bronchioles have several bronchial divisions within each lobe. Brokiolus
is a branch of the bronchi
Pulmonary alveoli is formed by about 300 million alveoli arranged in closter between
15-20 alveoli
Pulmonary Respiratory Physiology is an elastic structure wrapped in a thoracic cage,
which is a strong air chamber with a pressure-resistant wall.
The effect of this movement is to alternately increase and decrease the chest capacity.
Inspiration is when the capacity in the chest rises, air enters through the trachea.
The expiration is when the chest wall and the diaphragm return to their original size
3. Definitions
Pneumonia is an inflammation of the lung parenchyma caused by microorganisms-bacteria,
viruses, fungi, parasites (Djojodibroto, 2009). According to Corwin (2011) pneumonia is
an acute infection of lung tissue by microorganisms.
Clinically pneumonia is defined as a lung inflammation caused by microorganisms (bacteria,
viruses, fungi, parasites). Pneumonia caused by Mycobacterium tuberculosis is not
included. While pulmonary inflammation caused by nonmicroorganisms (chemicals,
radiation, aspiration of toxic substances, drugs and others) is called pneumonitis (PDDI,
2010).
Based on where the occurrence of pneumonia is divided into:
CAP (community-acquired pneumonia), acquired pneumonia in the community.
HAP (hospital-acqiured pneumonia / nosocomial pneumonia), acquired pneumonia at
the hospital.
5. Clinical Manifestations
Clinical symptoms and signs of pneumonia vary depending upon cause, age, immunological
status and severity of the disease. Clinical manifestations include shortness and cyanosis.
Symptoms and signs of pneumonia distinguished non-specific, pulmonary, pleural and
extrapulmonary symptoms.
1. Specific symptoms
A. Fever
B. Shivering
C. Sfalgia
D. Restless
E. Gastrointestinal disorders such as vomiting, bloating, diarrhea or abdominal pain
2. Pulmonary symptoms
A. Breath of the nostrils
B. Tachypnea, dyspnoea and apnea
C. Using intercostal and abdominal muscles
D. Cough
E. Wheezing
3. Pleural symptoms
Chest pain caused by Streptococcus pneumoniae and Staphylococcus aureus
4. Extrapulmonary symptoms
A. Skin or soft tissue abscess in case of pneumonia due to Staphylococus aureus
B. Otitis media, conjunctivitis, sinusitis can be found in cases of infection due to
Streptococcus pneumoniae or H. Influenza
6. Pathophysiology
Microorganisms enter the upper airway causing immune reactions and disturbed defense
mechanisms then form colonization of microorganisms resulting in inflammation. In
addition, bacterial toxins released directly damage the cells of the lower respiratory
system, including the production of alveolar II surfactants. Bacterial pneumonia results in
the most prominent immune and inflammatory response that travels clearly in
pneumococcal pneumonia (Corwin, 2011)
7. PATHWAY
8. Management
In the case of treating patients with pneumonia need to be considered clinical circumstances.
If the clinical condition is good and no indication of treatment can be treated at home.
Also note the presence or absence of modification factors that are conditions that may
increase the risk of infection with specific pathogenic microorganisms eg S. pneumoniae
resistant penicillin. According to ATS (2012), which is included in the factor of
modification are:
C. Pseudomonas aeruginosa
Bronchiectasis
Treatment of corticosteroids> 10 mg / day
Treatment of broad-spectrum antibiotics> 7 days in the last month
Malnutrition
9. Investigations
A. Radiological Overview
Photo thorax (PA / Lateral) which is the main investigation to make the diagnosis
B. Laboratory Examination
On laboratory examination there is an increase in the number of leukocytes, usually more
than 10,000 / ul sometimes up to 30,000 / ul, and on the leucocyte count there is a shift to
the left and an increase in LED. For examination of etiologic diagnosis sputum
examination, blood culture and serology are required. Blood cultures can be positive in
20-25 percent of untreated people. Blood gas analysis showed hypoxemia and hikarbia, at
an advanced stage may occur respiratory acidosis (PDPI, 2010).
10. Complications
Pleural effusion
Empyema
Pneumothorax
Piopneumothorax
Pneumatocell
Lung abscess
Sepsis
Failed breathing
functional paralytic Ileus
11. NURSING ASSURANCE
A. Data focus assessment
1. Client identity.
Pneumonia can attack all ages depending on the germs that cause bacterial pneumonia can
occur at any age, atypical pneumonia often in children and young adults, and viral
pneumonia is common in infants and children.
6. Physical examination.
A) General circumstances.
Client pneumonia conditions are generally weak, facial expressions withstand pain due to
stabbing chest pain.
B) Integumentary system.
On inspection of cyanisis and signs of skin turgor decline.
C) Respiratory system.
On the physical examination of the respiratory system will be found signs and symptoms as
follows:
Inspeksi : - Breathlessness and fatigue quickly.
- Early nonproductive cough becomes productive.
- Movements in the thorax on the diseased part are
left behind.
- Cyanosis occurs especially if the affected part of
the inflammation is quite large.
Vocal fremitus (vibration) will increase in intensity
Palpasi : on the sick side (more dense).
In the healthy part will sound the sonor and the sick
Perkusi : will sound dim (higher tone with shorter sound time).
Bronchial sound, a clear whisper, sometimes a
pleural friction.
Auskultasi :
D) Gastro intestinal system.
In Pneumonia clients found abdominal consolidation.
E) The celetal musculus system.
In Pneumonia clients frequent muscle weakness can occur
Disrupt the respiratory system.
B. Nursing diagnoses
1. Ineffective airway clearance associated with bronchial tracheal inflammation,
edema formation, increased sputum production.
2. The gas exchange disruption is related to the oxygen-carrying capacity
interference.
3. Disturbance of breath pattern associated with musculoskeletal gag
4. Activity intolerance is related to the imbalance between supply and oxygen
demand.
5. less nutrients than necessarily related to increased metabolic needs secondary to
fever and infection process.
6. Disturbance of fluid and eletrolite balance associated with excessive fluid loss,
decreased oral input.
A. Intervensi keperawatan
No Diagnosis Goal Intervensi Rasional
1. Ineffective airway 1. Assess the frequency / 1. Tachypnoea, shallow
After nursing care done
clearance is associated depth of breathing and breathing and
2x24 hours Effective
with bronchial tracheal chest movement. symmetrical chest
airway with the
inflammation, edema movements often occur
criteria:
formation, increased due to discomfort.
sputum production . 2. Auscultation of the 2. decreased blood flow
- Effective cough
lung area, note the occurs in the area of
- Normal breath area of decline 1 times consolidation with
there is airflow and fluid.
- The sound of a clean
the breath sound .
breath
3. patient may be
3. Explain the need for a
comfortable with high
break in the treatment
head, sleep in a chair.
plan and the need for a
balance of activity and
4. minimize fatigue and help
rest.
balance the supply and
oxygen demand.
4. Help the patient
choose a comfortable
position for rest or
sleep.