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Asuhan Keperawatan Pneumonia

Rencana Keperawatan Pneumonia

1. Ketidakefektifan Pola Nafas b.d Infeksi Paru

Karakteristik :
Batuk (baik produktif maupun non produktif) haluaran nasal, sesak nafas, Tachipnea, suara nafas terbatas, retraksi, demam, diaporesis, ronchii, cyanosis, leukositosis.


Tujuan :
Anak akan mengalami pola nafas efektif yang ditandai dengan :
- Suara nafas paru bersih dan sama pada kedua sisi
- Suhu tubuh dalam batas 36,5 – 37,2OC
- Laju nafas dalam rentang normal
- Tidak terdapat batuk, cyanosis, haluaran hidung, retraksi dan diaporesis


Intervensi
  • Lakukan pengkajian tiap 4 jam terhadap RR, S, dan tanda-tanda keefektifan jalan napas.
    R : Evaluasi dan reassessment terhadap tindakan yang akan/telah diberikan.
  • Lakukan Phisioterapi dada secara terjadwal
    R : Mengeluarkan sekresi jalan nafas, mencegah obstruksi
  • Berikan Oksigen lembab, kaji keefektifan terapi
    R : Meningkatkan suplai oksigen jaringan paru
  • Berikan antibiotik dan antipiretik sesuai order, kaji keefektifan dan efek samping (ruam, diare)
    R : Pemberantasan kuman sebagai faktor causa gangguan
  • Lakukan pengecekan hitung SDM dan photo thoraks
    R : Evaluasi terhadap keefektifan sirkulasi oksigen, evaluasi kondisi jaringan paru
  • Lakukan suction secara bertahap
    R : Membantu pembersihan jalan nafas
  • Catat hasil pulse oximeter bila terpasang, tiap 2 – 4 jam
    R : Evaluasi berkala keberhasilan terapi/tindakan tim kesehatan.


2. Defisit Volume Cairan b.d Penurunan intake cairan

Karakteristik :
Hilangnya nafsu makan/minum, letargi, demam., muntah, diare, membrana mukosa kering, turgor kulit buruk, penurunan output urine.


Tujuan :
Anak mendapatkan sejumlah cairan yang adekuat ditandai dengan :
  • Intake adekuat, baik IV maupun oral
  • Tidak adanya letargi, muntah, diare
  • Suhu tubuh dalam batas normal
  • Urine output adekuat, BJ Urine 1.008 – 1,020


Intervensi :
  • Catat intake dan output, berat diapers untuk output
    R : Evaluasi ketat kebutuhan intake dan output
  • Kaji dan catat suhu setiap 4 jam, tanda devisit cairan dan kondisi IV line
    R : Meyakinkan terpenuhinya kebutuhan cairan
  • Catat BJ Urine tiap 4 jam atau bila perlu
    R : Evaluasi obyektif sederhana devisit volume cairan
  • Lakukan Perawatan mulut tiap 4 jam
    R : Meningkatkan bersihan sal cerna, meningkatkan nafsu makan/minum



Diagnosis Keperawatan Pneumonia lain :
  1. Perubahan Nutrisi : Kurang dari kebutuhan b.d anoreksia, muntah, peningkatan konsumsi kalori sekunder terhadap infeksi
  2. Perubahan rasa nyaman b.d sakit kepala, nyeri dada
  3. Intoleransi aktivitas b.d distres pernafasan, latergi, penurunan intake, demam
  4. Kecemasan b.d hospitalisasi, distress pernafasan


Referensi :
Acton, Sharon Enis & Fugate, Terry (1993) Pediatric Care Plans,
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