Mata kuliah: Keperawatan Dasar

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

DISUSUN OLEH:
FATIN SYAHIRAH
202101114

DIII KEPERAWATAN
INSTITUT ILMU KESEHATAN PELAMONIA MAKASSAR
2022/2023
 FISIOLOGI RESPIRASI

1. Bersihan Jalan Nafas Tidak Efektif

a. Defenisi
Ketidakmampuan 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
 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
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.

2. Gangguan Penyapihan Ventilator

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

3. Gangguan Pertukaran Gas

a. Defenisi
Kelebihan atau kekurangan oksigen dan oksigenasi dan euleminasi
karbodioksida 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
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. 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
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 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
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
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.
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
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.
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.