Skip to main content

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

Comments

Popular posts from this blog

Appendicitis - Healing Acute Pain

Acute appendicitis is defined as the acute inflammation of the appendix. It is considered to be the most common cause of abdominal pain and distress in children and teenagers worldwide (ages 4-15). The appendix is a channel in its interior that communicates with the large intestine where feces semifluidas. The appendix is a small pouch attached to your large intestine. It is thought that appendicitis begins when the opening from the appendix into the cecum becomes blocked. The blockage may be due to a build-up of thick mucus within the appendix or to stool that enters the appendix from the cecum. When the appendix is blocked by calculus and feces or it is squeezed by the lymph nodes (due to bacterial infection, the lymph nodes usually become swollen and press against the appendix), it swells and usually doesn't receive enough blood. Bacteria grow inside the appendix, eventually causing its death. In acute appendicitis, the inflammation of the appendix is seriou...

Nursing Diagnosis for Rheumatoid Arthritis (RA)

Nursing Diagnosis for Rheumatoid Arthritis (RA) Rheumatoid Arthritis (RA) is a chronic, systemic inflammatory disorder that may affect many tissues and organs, but principally attacks synovial joints. The process produces an inflammatory response of the synovium (synovitis) secondary to hyperplasia of synovial cells, excess synovial fluid, and the development of pannus in the synovium. The pathology of the disease process often leads to the destruction of articular cartilage and ankylosis of the joints. Rheumatoid arthritis can also produce diffuse inflammation in the lungs, pericardium, pleura, and sclera, and also nodular lesions, most common in subcutaneous tissue. Although the cause of rheumatoid arthritis is unknown, autoimmunity plays a pivotal role in both its chronicity and progression, and RA is considered a systemic autoimmune disease. Nursing Diagnosis for Rheumatoid Arthritis (RA) Acute Pain / Chronic related to distention of tissue by the accu...

Nanda Approved Nursing Diagnosis 2010 -2011

NANDA Approved Nursing Diagnosis 2007-2008 contains 188 nursing diagnosis, latest NANDA-I Approved Nursing Diagnosis 2009-2011 contains an additional 21 new nursing diagnosis, 9 revisions diagnosis and some of diagnosis are not used again. Total nursing diagnosis at this time is 205 nursing diagnosis. Nanda I usually revised every 2 years, but this time NANDA I publish a list of NANDA Nursing Diagnosis for period of three years. for complete list of NANDA Approved Nursing Diagnosis 2009-2011, Source : Nanda - Approved Nursing Diagnosis 2010 -2011 : http://ncp-blog.blogspot.com/2010/11/nanda-approved-nursing-diagnosis-2010.html Related Articles