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
Labels:

Comments

Post a Comment

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...
Post a Comment
Read more

Stopping Panic Attacks Naturally

If you want to understand how to stop panic attacks naturally then it sounds like you are planning to go the self help option instead of making use of prescription drugs to manage your anxiety and panic. Anxiety attacks can be halted and there are incredible all natural means of accomplishing this. Panic and anxiety attacks start off in the brain and they are created in the area of the brain referred to as amygdala. This really is rather like a switch that turns anxiety and off. Controlling the amygdala is the vital thing to mastering precisely how to cease panic and anxiety attacks naturally. Panic and anxiety believe it or not accomplish a useful purpose as their function is to alert you of approaching threat so that you can do something to assure your own survival. This process is named the fight or flight response. Panic and anxiety symptoms happen once this process becomes too easily induced due to over excitement of this response. The good news is that panic attacks and anxi...
Post a Comment
Read more

3 Nursing Diagnosis for Pneumonia

3 Nursing Diagnosis for Pneumonia Nursing Diagnosis for Pneumonia and Nursing Interventions for Pneumonia 1. Nursing Diagnosis Knowledge Deficit : about the condition and the need for action Related to: Less exposed to information Less to remember Misinterpretation Possible evidenced by: Requests for information Statement of misconception Repeat mistakes Expected outcomes are: Stated understanding of disease processes and treatment conditions Do changes in lifestyle Nursing Interventions for Pneumonia : Review of normal lung function Discuss aspects of the inability of the disease, duration of healing and hope of recovery Provide written and verbal form Emphasize the importance of continuing effective cough Emphasize the need to continue antibiotic therapy for the recommended period. 2. Nursing Diagnosis for Pneumonia : Risk for Fluid Volume Deficit Risk factors: Excessive loss of fluids (fever, sweating, hyperventilation, vomiting) Expect...
Post a Comment
Read more