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Asuhan Keperawatan Bayi Berat badan Lahir rendah

Diagnosa Keperawatan yang Muncul
  1. Pola nafas tidak efektif b/d tidak adekuatnya ekspansi paru

  2. Gangguan pertukaran gas b/d kurangnya ventilasi alveolar sekunder terhadap defisiensi surfaktan

  3. Resiko tinggi gangguan keseimbangan keseimbangan cairan dan elektrolit b/d ketidakmampuan ginjal mempertahankan keseimbangan cairan dan elektrolit

  4. Perubahan nutrisi kurang dari kebutuhan tubuh berhubungan dengan tidak adekuatnya persediaan zat besi, kalsium, metabolisme yang tinggi dan intake yang kurang adekuat

  5. Resiko tinggi hipotermi atau hipertermi b/d imaturitas fungsi termoregulasi atau perubahan suhu lingkungan


Intervensi

Diagnosa Keperawatan 1. :
Pola nafas tidak efektif b/d tidak adekuatnya ekspansi paru

Tujuan
Pola nafas yang efektif

Kriteria Hasil :
  • Kebutuhan oksigen menurun
  • Nafas spontan, adekuat
  • Tidak sesak
  • Tidak ada retraksi


Intervensi
  • Berikan posisi kepala sedikit ekstensi
  • Berikan oksigen dengan metode yang sesuai
  • Observasi irama, kedalaman dan frekuensi pernafasan



Diagnosa Keperawatan 2. :
Gangguan pertukaran gas b/d kurangnya ventilasi alveolar sekunder terhadap defisiensi surfaktan

Tujuan
Pertukaran gas adekuat

Kriteria Hasil :
  • Tidak sianosis
  • Analisa gas darah normal
  • Saturasi oksigen normal.

Intervensi
  • Lakukan isap lendir kalau perlu
  • Berikan oksigen dengan metode yang sesuai
  • Observasi warna kulit
  • Ukur saturasi oksigen
  • Observasi tanda-tanda perburukan pernafasan
  • Lapor dokter apabila terdapat tanda-tanda perburukan pernafasan
  • Kolaborasi dalam pemeriksaan analisa gas darah
  • Kolaborasi dalam pemeriksaan surfaktan



Diagnosa Keperawatan 3. :
Resiko tinggi gangguan keseimbangan keseimbangan cairan dan elektrolit b/d ketidakmampuan ginjal mempertahankan keseimbangan cairan dan elektrolit

Tujuan
Hidrasi baik

Kriteria Hasil :
  • Turgor kulit elastik
  • Tidak ada edema
  • Produksi urin 1-2 cc/kgbb/jam
  • Elektrolit darah dalam batas normal

Intervensi
  • Observasi turgor kulit.
  • Catat intake dan output
  • Kolaborasi dalam pemberian cairan intra vena dan elektrolit
  • Kolaborasi dalam pemeriksaan elektrolit darah



Diagnosa Keperawatan 4. :
Perubahan nutrisi kurang dari kebutuhan tubuh berhubungan dengan tidak adekuatnya persediaan zat besi, kalsium, metabolisme yang tinggi dan intake yang kurang adekuat

Tujuan
Nutrisi adekuat

Kriteria Hasil :
  • Berat badan naik 10-30 gram / hari
  • Tidak ada edema
  • Protein dan albumin darah dalam batas normal

Intervensi
  • Berikan ASI/PASI dengan metode yang tepat
  • Observasi dan catat toleransi minum
  • Timbang berat badan setiap hari
  • Catat intake dan output
  • Kolaborasi dalam pemberian total parenteral nutrition kalau perlu



Diagnosa Keperawatan 5. :
Resiko tinggi hipotermi atau hipertermi b/d imaturitas fungsi termoregulasi atau perubahan suhu lingkungan

Tujuan
Suhu bayi stabil

Kriteria Hasil ;
  • Suhu 36,5 0C -37,2 0C
  • Akral hangat

Intervensi
  • Rawat bayi dengan suhu lingkungan sesuai
  • Hindarkan bayi kontak langsung dengan benda sebagai sumber dingin/panas
  • Ukur suhu bayi setiap 3 jam atau kalau perlu
  • Ganti popok bila basah
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