Impaired Gas Exchange related to decreased volumes and lung compliance, pulmonary perfusion and alveolar ventilation.
Goal: Signs and symptoms of respiratory disstres, deviation of the function and the risk of infant respiratory distress syndrome can be identified.
Outcomes:
- Demonstrate improved ventilation and adequate tissue oxygenation with blood gas analysis in the normal range.
- Free of symptoms of respiratory distress. Outcomes: Breathing does not use nasal flaring, intercostal retractions No, normal respiration, cyanosis (-), warm extremities.
- Clients showed improvement of ventilation and tissue oxygen levels with a blood gas analyzer in the normal range.
Intervention
1. Monitor dyspnea, tachypnea, breath sounds, increased respiratory effort, lung expansion, and weakness.
R :/ Pulmonary tuberculosis resulted in far-reaching effects on the lungs of a small part of bronchopneumonia to inflammatory wide diffusion, necrosis. Pleural effusion, and extensive fibrosis. The effect on respiratory symptoms vary from mild, severe dyspnea, until respiratory distress.
2. Evaluation of changes in the level of consciousness, cyanosis noted, and skin color changes, including mucous membranes and nails.
R :/ accumulation of secretions, and less healthy lung tissue oxygenation can disrupt the body's vital organs and tissues.
3. Support the lip breathing during expiration, especially for clients with fibrosis and lung parenchymal damage.
R :/ Creating custody fight outside air to prevent collapse / narrowing of the airway that helps spread the air through the lungs and reduce shortness of breath.
4. Assessing mental status.
R :/ weakness, irritability, confusion can merefleksikana presence of hypoxemia / decrease in cerebral oxygenation.
5. Oxygen delivery in accordance with the additional requirements.
R :/ Oxygen therapy can correct the hypoxemia that occurs due to decreased ventilation / decrease in pulmonary alveolar surface.
Imbalanced Nutrition: Less Than Body Requirements related to the inability to suck, decreased intestinal motility.
Goal: Maintain and support the nutritional intake
Outcomes:
- The client demonstrates adequate food intake and metabolismetubuh.
- Increased food intake, there is no further weight loss, expressed feelings of well-being.
Interventions :
1. Give IV fluids containing glucose as needed neonates.
R :/ Food portions are a little but often requires less energy.
2. Identifying the factors which cause difficulty in swallowing.
R :/ To be able to select interventions according to the cause.
3. Refer to dietitian for help choosing a liquid that can meet the nutritional needs.
R :/ Dieticians are specialized in nutritional science that can help clients mimilih foods that meet the needs of calories and nutritional needs according to the state of illness, age, height, weight.
Ineffective family coping related to anxiety, guilt, and parting with the baby as a result of a crisis situation
Goal: Minimizing anxiety and guilt, and support bounding between parent and infant.
Outcomes:
- Family clients reveal knowledge about the disease suffered by the patient.
- Can be reported immediately to the medical team if something suddenly happens to the patient.
- Families of patients can stabilize emotions.
Interventions :
1. Assess verbal and non-verbal responses of parents of anxiety and the use of coping mechanisms.
R :/ This will help identify and build effective coping strategies.
2. Help parents verbally express his feelings about the condition of sick children, old care intensive unit, procedure and treatment of infants.
R :/ Creating parents to express their feelings freely so that helps establish mutual trust, as well as reduce the level of anxiety.
3. Provide accurate and consistent information on the condition of infant development.
R :/ information can reduce anxiety.
4. Whenever possible, encourage parents to visit and get involved in their care.
R :/ Facilitate the bounding process.
