Asuhan Keperawatan Bayi Berat badan Lahir rendah

Diagnosa Keperawatan yang Muncul

Pola nafas tidak efektif b/d tidak adekuatnya ekspansi paru

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

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

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

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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