I.01011 Manajemen Jalan Napas

Definisi : Mengidentifikasi dan mengelola kepatenan jalan napas

Tindakan

Observasi

  1. Monitor pola napas (frekuensi, kedalaman, usaha napas)
  2. Monitor bunyi napas tambahan (mis. gurgiling, mengi, wheezing, ronkhi kering)
  3. Monitor sputum (jumlah, warna, aroma)

Terapeutik

  1. Pertahanan kepatenan jalan napas dengan head-tift dan chin-lift (jaw-thrust jika curiga trauma servikal)
  2. Posisikan Semi-Fowler atau Fowler
  3. Berikan minuman hangat
  4. Lakukan fisioterapi dada, jika perlu
  5. Lakukan penghisapan lendir kurang dari 15 detik
  6. Lakukan hiperoksigenasi sebelum penghisapan endotrakeal
  7. Keluarkan sumbatan benda padat dengan proses McGill
  8. Berikan Oksigen, Jika perlu

Edukasi

  1. Anjurkan asupan cairan 2000 ml/hari, Jika tidak komtraindikasi
  2. Ajarkan teknik batuk efektif

Kolaborasi

  1. Kolaborasi pemberian bronkodilator, ekspektoran, mukolitik, Jika perlu

Daftar Pustaka

PPNI (2018). Standar Intervensi Keperawatan Indonesia.

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    D.0001 Bersihan Jalan Napas Tidak Efektif - Mind Full Ners

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    Mei 18, 2024

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    Mei 31, 2024

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    Juni 14, 2024

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