NANDA Definition: The exchange of air inspiration and / or expiration inadequate.
Characteristics:
- Decrease pressure inspiration / expiration
- Decrease in air changes per minute
- Using additional respiratory muscle
- Nasal flaring
- Dyspnea
- Orthopnea
- Changes in chest deviation
- Shortness of breath
- Assumption of 3-point position
- Breathing pursed-lip
- Phase lasts very long expiratory
- Increased anterior-posterior diameter
- Respiratory average / minimum
- Infants: less than 25 or more than 60
- Age 1-4: less than 20 or more than 30
- Age 5-14: less than 14 or more than 25
- Age over 14: less than 11 or more than 24
- Depth of respiration
- Adult tidal volume of 500 ml at rest
- Infant tidal volume of 6-8 ml / kg
- Timing ratio
- Decrease in vital capacity
Heart Failure
Congestive heart failure is a pathophysiological state of abnormalities in cardiac function so that the heart is not able to pump blood to meet the metabolic needs of tissues and or ability to exist if accompanied by an abnormal elevation of diastolic volumes.
Predisposing factor is a disease that causes decreased ventricular function and the circumstances that limit ventricular filling. Precipitating factors including an increased intake of salt, anti-disobedient treatment of heart failure, AMI (possibly hidden), an attack of hypertension, acute arrhythmia, infection or fever, pulmonary embolism, anemia, thyrotoxicosis, pregnancy and infective endocarditis.
Nursing Diagnosis Ineffective Breathing Pattern for Congestive Heart Failure (CHF)
Goal: The pattern of breathing effectively, after the act of diving in hospital nursing, respiration normal, no additional breath sounds and the use of auxiliary respiratory muscles. And normal blood gas analysis.
Expected Outcomes:
- Regular breathing pattern
- Respiration returned to normal 16-24 times / minute
1. Monitor respiratory depth, frequency, and chest expansion.
Rationale: Knowing the level of excess oxygen demand
2. Note the respiratory efforts include the use of auxiliary breathing muscles.
Rationale: Indicates oxygen therapy
3. Auscultation of breath sounds and note if there are additional breath sounds.
Rational: To declare the existence of pulmonary congestion or accumulation of secretions. Indicate the need for further intervention.
4. Elevate the head (position semifowler) and help to achieve a comfortable position. Collaboration of Oxygen and BGA inspection.
Rational: Meningggikan head and semi-Fowler position to reduce the burden and meringakan effort to breathe.
