Mata kuliah : keperawatan dasar

Dosen : Ns. Zakariati, SKM,.S.Kep,.M.Kep

Di susun oleh :
Nama : Supriani
Nim : 202101096

D III KEPERAWATAN
INSTITUT ILMU KESEHATAN PELAMONIA MAKASSAR
TA: 2022/2023

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 FISIOLOGI RESPIRASI

1. Bersihan Jalan Nafas Tidak Efektif

a. Defenisi
Ketidak mampuan membersihkan secret atau obstruksi jalan
napas untuk mempertahankan jalan napas tetap paten.
b. Penyebab
 Fisiologis
1. Spasme jalan napas
2. Hipersekresi jalan napas
3. Disfungsi neuromuskuler
4. Benda asing dalam jalan napas
5. Adanya jalan napas buatan
6. Sekresi yang tertahan
7. Hyperplasia dinding jalan napas
8. Proses infeksi
9. Respon alergi
10. Efek agen farmakologis (mis. Anastesi)

 Situasional
1. Merokok aktif
2. Merokok pasif
3. Terpajan polutan
c. Gejala dan tanda mayor

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  Subjektif
Tidak tersedia
 Objektif
1. Batuk tidak efektif atau tidak mampu batuk
2. Sputum berlebih / abstruksi di jalan napas / meconium
di jalan napas (pada neonates)
3. Mengi, wheezing dan / atau ronkhi kering
d. Gejala dan tanda minor
 Subjektif
1. Dispnea
2. Sulit bicara
3. Ortopnea
 Objektif
1. Gelisah
2. Sianosis
3. Bunyi napas menurun
4. Frekuensi napas berubah
5. Pola napas berubah
e. Kondisi klinis terkait
1. Gullian barre syndrome
2. Sklerosis multiple
3. Myasthenia gravis
4. Prosedur diagnotik (mis. Bronkoskopi, transesophageal
echocardiography [TEE]
5. Depresi system saraf pusat
6. Cedera kepala
7. Stroke
8. Kuadriplegia
9. Sindrom aspirasi mekonim
10. Infeksi saluran napas
11. Asma

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f. Referensi
Ackley, B. J., Ladwig, G. B., & Makic, M. B. F. (2017). Nursing
diagnosis handbook, an evidence-based guide to planning care.
11th Ed. St. Louis: Elsevier.
Brukwitzki G. Holmgren C & Maibusch RM (1996) Validation of
the defining characteristics of the nursing diagnosis ineffective
airway clearance. Nursing Diagnoses, 7, 63-69.
Carlson-Catalano, J., Lunney, M., Paradiso, C., Bruno J., Luise
B. K., Martin, T., Massoni, M., & Pachter, S. (1998). Clinical
validation of ineffective breathing pattern, ineffective airway
clearance and impaired gas exchange. Journal of Nursing
Scholarship, 30, 243-248.
Carpernito-Moyet, L. J. (2013). Nursing diagnosis application to
clinical practice. 14th Ed. Philadelphia: Lippincott Williams &
Wilkins.
Newfield, S. A., Hinz, M. D., Tiley, D. S., 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. 6th Ed. Philadelphia: F.A. Davis
Companny.
Pascoal, L. M., Lopes, M. O., da Silva, V. M., Beltrão, B. A.,
Chaves, D. R., Herdman, T. H., &... Costa, A. S. (2016). Clinical
indicators of ineffective airway clearance in children with acute
respiratory infection. Journal Of Child Health Care: For
Professionals Working with Children in the Hospital And
Community, 20(3), 324-332. doi:10.1177/1367493515598648.
V.E.C. de Seosa, M. V. de Oliveira Lopes & V. M. da Silva
(2014). Systematic Review and Meta-analysis of Accuracy of
Clinical Indicators of Ineffective Airway Clearance. JAN, 498-
513.

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2. Gangguan Penyapihan Ventilator
a. Defenisi
Ketidak mampuan beradaptasi dengan pengurangan bantuan
ventilator mekanik yang dapat menghambat dan memperlama
proses penyapihan.
b. Penyebab
 Fisiologis
1. Hipersekresi jalan napas
2. Ketidakcukupan energi
3. Hambatan upaya napas (mis. Nyeri saat bernapas,
kelemahan otot pernapasan, efek sedasi)
 Psikologis
1. Kecemasan
2. Perasaan tidak berdaya
3. Kurang informasi tentang proses penyepihan
4. Penurunan motivasi
 Situasional
1. Ketidakadekuatan dukungan social
2. Ketidaktepatan kecepatan proses penyapihan
3. Riwayat kegagalan berulang dalam upaya
penyapihan
4. Riwayat ketergantungan ventilator >4 hari
c. Gejala dan tanda mayor
 Subjektif
Tidak tersedia

 Objektif
1. Frekuensi nafas meningkat
2. Penggunaan otot bantu napas
3. Napas megap-megap (gasping)

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 4. Upaya napas dan anuan ventilator dan singkron
5. Napas dangkal
6. Agitasi
7. Nilai gas darah arteri abnormal
d. Gejala dan tanda monir
 Subjektif
1. Lelah
2. Kuatir mesin rusak
3. Focus meningkat pada pernapasan
 Objektif
1. Auskultasi suara inspirasi menurun
2. Warna kulit abnormal ( mis. Pucat, sianosis)
3. Napas paradoks abdominal
4. Diaphoresis
5. Ekpresi wajah takut
6. Tekanan darah meningkat
7. Frekuensi nadi meningkat
8. Kesadaran menurun
9. Gelisah
e. Kondisi klinis terkait
1. Cedera kepala
2. Coronary arrrtery bbypass graft (CABG)
3. Ggagal napas
4. Cardiact arrest
5. Tranplantasi jantung
6. Displasi bronkopulmonal
f. Referensi
Ackley, B. J., Ladwig, G. B., & Makic, M. B. F. (2017). Nursing
diagnosis handbook, an evidence-based guide to planning care.
11th Ed. St. Louis: Elsevier. Carpemito-Moyet, L. J. (2013).
Nursing diagnosis application to clinical practice. 14th Ed.

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Philadelphia: Lippincott Williams & Wilkins. Gimenez, A.,
Fernandez-Reyes, I., Marin, B., Alvarez, M., Andorra, M.,
Duque, F., &
Tomas, A. (1997). Methodology for the validation of the
diagnostic
content of dysfuncional [sic] Ventilatory Weaning Response
(DVWR).
Enfermeria Clinica, 7(6), 255-262. Giménez, A. M., Serrano, P.,
& Marin, B. (2003). Clinical validation of dysfunctional ventilatory
weaning response: The Spanish experience. International
Journal Of Nursing Terminologies And Classifications: The
Official Journal
Of NANDA International, 14(2), 53-64. Gomes Brandão, M. A.,
Cerqueira, F. A., Matos, L. N., Campos, J. F., Pinto Peixoto,
M. A., & Primo, C. C. (2014). Defining characteristics of the
Dysfunctional Ventilatory Weaning Response as indicators of
accuracy of ventilatory weaning. Revista Brasileira De
Enfermagem, 67(5), 737-743. doi:10.1590/0034-
7167.2014670510.
Macintyre, N. R. (2012). Evidence-based assessments in the
ventilator
discontinuation process. Respiratory Care, 57(10), 1611-1618.
Newfield, S. A., Hinz, M. D., Tiley, D. S., Sridaromont, K. L.,
Maramba, P. J. (2012). Cox's clinical applications of nursing
diagnosis. 6th Ed. Philadelphia: F.A. Davis Companny.

Rose, L., Dainty, K. N., Jordan, J., et al. (2014). Weaning from
mechanical ventilation: a scoping review of qualitative studies.
American Journal of Critical Care, 23(5), e54-e71.
Yucel, S., et al. (2011). Nursing diagnoses in patients having
mechanical ventilation support in a respiratory intensive care

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 unit in Turkey. International Journal of Nursing Practice, 17(5),
502-508.

3. Gangguan Pertukaran Gas

a. Defenisi
Kelebihan atau kekurangan oksigenasi dan / aau eliminasi
karbondioksida pada membrane alveolus-kapiler
b. Penyebab
1. Ketidakseimbangan ventilasi-perfusi
2. Perubahan membrane alveolus-kapiler
c. Gejala dan tanda mayor
 Subjektif
1. Dispnea
 Objektif
1. PCO2 meningkat/menurun
2. PO2 menurun
3. Takikardia
4. pH arteri meningkat/menurun
5. bunyi napas tambahan
d. Gejala dan tanda minor
 Subjektif
1. Pusing
2. Penglihatan kabur

 Objektif
1. Sianosis
2. Diaphoresis
3. Gelisah
4. Napas cuping hiodung

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 5. Pola napas abnormal (cepat/lambat, regular/ireguler,
dalam/dangkal)
6. Warna kulit abnormal (mis. Pucat, kebiruan)
7. Kesadaran menurun
e. Kondisi klinis tekait
1. Penyakit paru abstruktif kronis (PPOK)
2. Gagal jantung kongestif
3. Asma
4. Pneumonia
5. Tuberkolosis paru
6. Penyakit membrane hialin
7. Asfiksia
8. Persistent pulmonary hypertension of newborn
9. Prematuritas
10. Infeksi saluran nafas
f. Referensi
Ackley, B. J.,Ladwig, G. B., & Makic, M. B. F. (2017). Nursing
diagnosis handbook, an evidence-based guide to planning care.
11th 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
B. K., Martin, T., Massoni, M., & Pachter, S. (1998). Clinical
validation of ineffective breathing pattern, ineffective airway
clearance and impaired gas exchange. Journal of Nursing
Scholarship, 30, 243-248. Carpernito-Moyet, L. J. (2013).
Nursing diagnosis application to clinical practice. 14 th
Ed. Philadelphia: Lippincott Williams & Wilkins. Newfield, S. A.,
Hinz, M. D., Scott-Tilley, D., Sridaromont, K. L., & Maramba, P.

9
 J. (2012). Cox's clinical applications of nursing diagnosis. 6th
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.

4. Gangguan Ventilasi Spontan

a. Definisi
Penurunan cadangan energi yang mengakibatkan individu tidak
mampu bernapas secara adekuat.
b. Penyebab
1. Gangguan metabolism
2. Kelemahan otot pernapasan
c. Gejala dan tanda mayor
 Subjektif
Tidak tersedia

 Objekif
1. Penunaan otot bantu napas meningkat
2. Volume tidal menurun
3. PCO2 meningkat
4. PO2 menurun

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 5. SaO2 menurun
d. Gejala dan tanda minor
 Subjekif
Tidak tersedia
 Objektif
1. Gelisah
2. Takikardia
e. Kondisi klinis terkait
1. Penyakit paru obstruktif kronis (PPOK)
2. Asma
3. Cedera kepala
4. Gagal napas
5. Bedah jantung
6. Adult respiratory distress syndrome (ARDS)
7. Persistent pulmonary hypertension of newborn (PPHN)
8. Prematuritas
9. Infeksi saluran nafas
f. Referensi
Ackley, B. J., Ladwig, G. B., & Makic, M. B. F. (2017). Nursing
diagnosis handbook, an evidence-based guide to planning care.
11th Ed. St. Louis: Elsevier. Carpernito-Moyet, L. J. (2013).
Nursing Diagnosis Application to Clinical Practice. 14 Ed.
Philadelphia: Lippincott Williams & Wilkins.
Coucher, B. (2014). The challenge of diagnosing dyspnea.
AACM dvanced Critical Care, 25(3), 284-290.
Do Canto, D. F., & Almeida, M. A. (2013). Nursing outcomes for
ineffective breathing patterns and impaired spontaneous
ventilation in intensive care. RevistaGaúcha De Enfermagem /
EENFUFRGS, 34(4), 137-145.
Newfield, S. A., Hinz, M. D., Tiley, D. S., Sridaromont, K. L.,
Maramba, P. J. (2012). Cox's Clinical Applications of Nursing

11
 Diagnosis Adult, Child, Women's, Mental Health, Gerontic, and
Home Health Considerations. 6th Ed. Philadelphia: F.A. Davis
Companny.
Parshall, M. B., Schwartzstein, R. M., Adams, L., et al. (2011).
An offcial American thoracic society statement: update on the
mechanisms, assessment, and management of dyspnea.
American Journal of Respiratory & Critical Care Medicine,
185(4), 435-452.
Zeitoun, S. S., de Barros, A. L., Michel, J. M., & de Bettencourt,
A. C. (2007). Clinical validation of the signs and symptoms and
the nature of the respiratory nursing diagnoses in patients under
invasive mechanical ventilation. Journal of Clinical Nursing,
16(8), 1417-1426.

5. Pola Napas Tidak Efektif

a. Defenisi
Inspirasi dan/atau ekspirasi yang tidak memberikan ventilasi
adekuat.
b. 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

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 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 farmakologi
15. Kecemasan
c. Gejala dan tanda mayor
 Subjektif
1. Dispnea
 Objektif
1. Penggunaan otot bantu pernapasan
2. Fase ekspirasi memanjang
3. Pola napas abnormal (mis. Takipnea, bradypnea,
hiperventilasi, kussmaul, chyne-stokes)
d. Gejala dan tanda minor
 Subjektif
Ortopnea
 Objektif
1. Pernapasan pursed-lip
2. Pernapasan cuping hidung
3. Diameter thoraks anterior-pasterior meningkat
4. Ventilasi semenit menurun
5. Kapasitas vital menurun
6. Tekanan ekspirasi menurun
7. Tekanan inspirasi menurun
8. Ekskursi dada berubah

e. Kondisi klinis terkait

1. Depresi system saraf pusat

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 2. Cedera kepala
3. Trauma thoraks
4. Gullian barre syindrome
5. Sclerosis multiple
6. Myasthenia gravis
7. Stroke
8. Kuadriplegia
9. Intoksikasi alcohol
f. Referensi
Ackley, B. J., Ladwig, G. B., & Makic, M. B. F. (2017). Nursing
diagnosis handbook, an evidence-based guide to planning care.
11th 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
B. K., Martin, T., Massoni, M., & Pachter, S. (1998). Clinical
validation of ineffective breathing pattern, ineffective airway
clearance and impaired gas exchange. Journal of Nursing
Scholarship, 30, 243-248.
Carpernito-Moyet, L. J. (2013). Nursing Diagnosis Application to
Clinical Practice. 14th Ed. Philadelphia: Lippincott Williams &
Wilkins. Coucher, B. (2014). The challenge of diagnosing
dyspnea. AACN Advanced Critical
Care, 25(3), 284-290.
Newfield, S. A., Hinz, M. D., Tiley, D. S., 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. 6th Ed.

14
 Philadelphia: F.A. Davis Companny. Parshall, M. B.,
Schwartzstein, R. M., Adams, L., et al. (2011). An offcial
American thoracic society statement: update on the
mechanisms, assessment, and management of dyspnea.
American Journal of Respiratory & Critical Care Medicine,
185(4), 435-452.
Zeitoun, S. S., de Barros, A. L., Michel, J. M., & de Bettencourt,
A. C. (2007). Clinical validation of the signs and symptoms and
the nature of the respiratory nursing diagnoses in patients under
invasive mechanical ventilation. Journal of Clinical Nursing,
16(8), 1417-1426.

6. Risiko Aspirasi
a. Defenisi
Beresiko mengalami masuknya sekresi gastrointestinal, sekresi
orofaring, benda cair atau benda padat ke dalam saluran
trakeobronkhial akibat di fungsi mekanisme protektif saluran
nafas
b. Factor resiko
1. Penurunan tingkat kesadaran
2. Penurunan refleks muntah dan/atau batuk
3. Gangguan menelan
4. Disfagia
5. Kerusakan mobilitas fisik
6. Peninglkatan rsidu lambung
7. Peningkatan tekanan intragastric
8. Penurunan motolitas gastrointestinal
9. Sfingter esofagus bawah inkompoten
10. Perlambatan pengosongan lambung
11. Terpasang selang nasogastric

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 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.
c. Kondisi klinis terkait
1. Cedera kepala
2. Stroke
3. Cedera medulla spinalis
4. Guillain barre syndrome
5. Penyakit parkison
6. Keracunan obat dan alcohol
7. Pembesaran uterus
8. Miestenia gravis
9. Fistula trakeoesofagus
10. Striktura esofagus
11. Skelrosis multiple
12. Labiopala toskizis
13. Atresia esofagus
14. Laringomalasia
15. Prematuritas

d. Referensi
Ackley, B. J., Ladwig, G. B., & Makic, M. B. F. (2017). Nursing
diagnosis handbook, an evidence-based guide to planning care.
11th Ed. St. Louis: Elsevier. Brodsky, D.,Ouellette, M.A. (2008).
Primary care of the premature infant. Philadelphia: Saunders.

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Carpernito-Moyet, L. J. (2010). Nursing diagnosis application to
clinical practice. 13th
Ed. Philadelphia: Lippincott Williams & Wilkins. Chapman, L.,
Durham, R.F. (2010). Maternal-newborn nursing: The critical
components of nursing care. Philadelphia: F.A Davis Company.
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2013).
Nursing diagnosis manual planning, individualizing and
documenting client care. 4th Ed. Philadelphia: F. A. Davis
Company. Frota Cavalcante, T., Leite de Araujo, T., Pessoa
Moreira, R., Gomes Guedes, N., Venicios de Oliveira Lopes, M.,
& Martins da Silva, V. (2013).
Clinical validation 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. Surrena, H. (2010). Handbook for
medical-surgical nursing. Philadelphia: Wolters Kluwer Health.
Wooldridge,J., Herman, J., Garrison, C., Haddock, S., Massey,
J., & Tavakoli, A. (1998). A validation study using the case-
control method of the nursing diagnosis high risk for aspiration.
Nursing Diagnosis: ND: The Official Journal Of The North
American Nursing Diagnosis Association, 9(1), 5 13.

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