I.01014 Pemantauan Respirasi

Definisi : Mengumpulkan dan menganalisis data untuk memastikan kepatenan jalan napas dan keefektifan pertukaran gas

Tindakan

Observasi

  1. Monitor frekuensi, irama, kedalaman dan upaya napas
  2. Monitor pola napas (seperti bradipnea, takipnea, hiperventilasi, kussmaul, Cheyne-Stokes, biot, ataksik)
  3. Monitor kemampuan bantuk efektif
  4. Monitor adanya produksi sputum
  5. Monitor adanya sumbatan jalan napas
  6. Palpasi kesimetrisan ekspansi paru
  7. Auskultasi bunyi napas
  8. Monitor saturasi oksigen
  9. Monitor nilai AGD
  10. Monitor hasil x-ray toraks

Teraupetik

  1. Atur interval pemantauan respirasi sesuai kondisi pasien
  2. Dokumentasikan hasil pemantauan

Edukasi

  1. Jelaskan tujuan dan prosedur pemantauan
  2. Informasikan hasil pemantauan, jika perlu

Daftar Pustaka

PPNI (2018). Standar Intervensi Keperawatan Indonesia.

63 Semua Komentar

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