Nama
:
Diagnosa Medis
:
No. RM
:
Tanggal pengkajian :
GL/
AM
NO.
DX
1
SUBYEKTIF
OBYEKTIF
Pola nafas :
tidur
tachipnea, bradipnea,
Badan lemas
hiperventilasi atau
Capek
hipventilasi
Kelelahan
Terpasang
ventilator dengan
Tidurterlentang
mode kendali penuh
tidak bisa
ANALISA
Pola nafas tidak efektif
RR > 25 x/m
Ekaspansi dada
tidak maksimal dan
tidak simetris
Saturasi
mencapai < 95 %
PaO2 < 80
mmHg, dengan FiO2
21%, PCO2 > 45
mmHg.
distress nafas
(Kelelahan, kesadaran menurun,
dipsnea, tachipnea,
bradipnea,apnea, retraksi otot
dada, PCH, sianosis )
PERENCANAAN
Mandiri
EVALUASI
Jam :
Subyektif :
1. Mengatur posisi head up / semi fowler 45
...................................
derajat
2. Mengobservasi pola pernafasan, Hitung dan ...................................
Catat frekwensi Pernafasan dan saturasi
...................................
Oksigen tiap ..............................................................
...................................
3. Mengobservasi tanda tanda distress
...................................
Nafas tiap ................................................................
...................................
4. Pertahankan kepatenan jalan Nafas
...................................
Dengan melakukan penghisapan sputum sesuai
Obyektif :
kebutuhan, atau pasang ett, oro/nasofaringeal tube/
...................................
tracheal tube
...................................
5. Memastikan adanya keluhan kelemahan otot dan
...................................
kesulitan bernafas tiap ..
...................................
Kolaborasi
...................................
6. Seting ventilator mekanik sesuai
...................................
program dokter
...................................................................................
...................................
Assesment :
.
...................................
...................................
.
...................................
7. Tentukan kebutuhan oksigen dimulai
...................................
dengan FiO2
...................................
.......
Planning :
...................................
.
...................................
8. Pantau Analisa gas darah
...................................
tiap .....................................
...................................
sampai tanda hipoksemia teratasi.
...................................
9. Memberikan Obat obatan sedasi/muscle relaxan/
...................................
10. Bronchodilator/anti inflamasi/antipiretik
GL/
AM
NO.
DX
2
SUBYEKTIF
bisa
mengeluarka
n sputum/
dahak
Sesak
Tidak
Mengelu
arkan dahak
tidak puas
OBYEKTIF
ANALISA
PERENCANAAN
EVALUA
Jam :
Subyektif :
......................
......................
......................
......................
......................
......................
......................
Obyektif :
......................
......................
......................
......................
......................
......................
......................
Assesment :
......................
......................
......................
......................
......................
Planning :
......................
......................
......................
......................
......................
......................
......................
......................
GL/
AM
NO.
DX
3
SUBYEKTIF
Sesak nafas
Tidak bisa
tidur
Badan lemas
Capek
Kelelahan
Tidur
terlentang
tidak bisa
OBYEKTIF
ANALISA
PERENCANAAN
EVALUASI
Jam :
Pola nafas
Gangguan pertukaran Mandiri
1. Kaji dan dokumentasikan pola nafas, RR, kedalaman
Subyektif :
tidak adekuat
gas
irama dan simetris sistim
...................................
Pola nafas :
pernafasan
tiap
jam
tiap
jam
...................................
tachipnea,
2.
Pertahankan
jalan
nafas
...................................
bradipnea,
(
Pakai
ett,Traceocanule,
...................................
hiperventilasi atau
Oro/nasofaringeal
tube
)
...................................
hipventilasi
3.
Kaji
pengembangan
paru,
...................................
Terpasang
pengunaan otot2 asesoris dan suara
...................................
ventilator dengan
nafas tiap shift
Obyektif :
mode kendali penuh
4. Atur posisi semi fowler/ 45 derajat
...................................
atau sebagian,
5. Batasi aktifitas
...................................
dengan Fio2 > 40%
6. Bantu ADL
...................................
RR > 25 x/m
7. Hindari hipertermia
...................................
Ekaspansi dada
8. Pantau tanda distress nafas
...................................
tidak maksimal dan
( Tanda tanda distress
...................................
tidak simetris
Kelelahan, kesadaran menurun,
...................................
Saturasi
dipsnea, tachipnea, bradipnea,apnea,
Assesment :
mencapai < 95 %
retraksi otot dada, PCH, sianosis )
...................................
PaO2 < 80
Kolaborasi
...................................
9. Menberi Seting ventilator mekanik sesuai
mmHg, dengan FiO2
...................................
program dokter
21%, PCO2 > 45
...................................
........................................................................................
mmHg.
...................................
Planning :
distress nafas
dengan
FiO2
....................
...................................
(Kelelahan, kesadaran
...................................
menurun, dipsnea, tachipnea,
11.
Memantau
Analisa
gas
darah
...................................
bradipnea,apnea, retraksi otot
tiap
.......................................................................................
...................................
dada, PCH, sianosis )
.
...................................
12. Foto thorax tiap..............................................................
...................................
sampai tanda hipoksemia teratasi.
..................................
13. Memberikan Obat obatan sedasi/muscle relaxan/
Bronchodilator/anti inflamasi/antipiretik
................................................................. ................
GL/
AM
NO.
DX
4
SUBYEK
TIF
OBYEKTIF
ANALISA
PERENCANAAN
EVALUASI
Jam :
Nutrisi kurang dari Mandiri
Subyektif :
kebutuhan
1. Mengkaji status nutrisi klien
...................................
2. Menghitung kebutuhan kalori setiap
...................................
hari ...................................................................
...................................
3. Menghitung kebutuhan cairan dan
...................................
Elektrolit (Na,K ) setiap hari ............................
...................................
...........................................................................
...................................
4. Mengkaji reflek menelan, Gag reflek,
...................................
kemampuan batuk efektif tiap...........................
Obyektif :
...........................................................................
...................................
5. Tentukan rute pemberian nutrisi.......................
...................................
...........................................................................
...................................
6. Mengauskultasi bising Usus tiap shift
...................................
7. Pantau Residu lambung sebelum memasukan
...................................
diet berikutnya
...................................
8. Atur posisi head up selama dan sesudah
...................................
Makan
Assesment :
9. Menghitung asupan kalori yang berhasil ...................................
dikonsusmsi oleh klien
...................................
perhari tiap hari
...................................
10. Pantau Intake dan out put cairan Setiap hari...................................
11. Pantau tanda marasmus kwasiorkor
...................................
12. Pantau berat badan setiap minggu
Planning :
13. Memantau antropometri klien setiap
...................................
Minggu..
...................................
Kolaborasi
...................................
14. Memberikan nutrisi parenteral sesuai order
...................................
dokter
...................................
15. Melakukan pemeriksaan Kadar Gula darah,
...................................
GL/
AM
...................................
..................................
NO.
DX
5
SUBYEKTIF
OBYEKTIF
ANALISA
PERENCANAAN
Perubahan
volume Mandiri
1. Mengkaji membran mukosa dan
cairan dan elektrolit
turgor kulit tiap jam
kurang
dari
2.
Memasang
IV line dan Dower kateter
kebutuhan
3.
4.
5.
6.
EVALUASI
Jam :
Subyektif :
...................................
...................................
Memantau intake dan output tiap shift
...................................
Memonitoring EKG tiap.................................................
...................................
........................................................................................
...................................
Memonitoring TTV tiap shift
Menghindari hipertermia
...................................
...................................
Kolaborasi
Obyektif :
7. Memberikan cairan sesuai order dokter.........................
...................................
.......................................................................................
8. Memberikan koreksi kekurangan atau kelebihan ...................................
...................................
kadar elektrolit...............................................................
.......................................................................................
...................................
.......................................................................................
...................................
9. Melakukan pemeriksaan kadar serum elektrolit, BUN,
...................................
U,C, HCT,
...................................
Berat jenis plasma dan urine..........................................
Assesment :
........................................................................................
...................................
10. Memantau osmolalitas plasma tubuh.............................
.........................................................................................
...................................
.......................................................................... ...................................
...............
...................................
..........................................................................
.......................................................................... ...................................
.......................................................................... Planning :
.......................................................................... ...................................
.......................................................................... ...................................
.......................................................................... ...................................
..........................................................................
...................................
..........................................................................
.......................................................................... ...................................
..........................................................................
..........................................................................
.......................................................
CATATAN PERKEMBANGAN (DX 6 ) PERUBAHAN VOLUME CAIRAN DAN ELEKTROLIT LEBIH DARI KEBUTUHAN
Nama
:
Diagnosa Medis
:
No. RM
:
Tanggal pengkajian :
GL/
AM
...................................
...............................
NO.
DX
6
SUBYEKTIF
OBYEKTIF
Intake lebih banyak
dari dan output
Produksi urine > 0,5
1 ml/kg/jam
Turgor kulit normal
Ronchi positif
Whezzing positif
CVP > 1O mmHg
PCWP 8 12 mmHG
atau meningkat
Suhu tubuh normal
36,5 37,5 derajat
Membran mukosa
lembab
SBP > 90 120 mmHg
DBP > 60 - 90 mmHg
Nadi>70 90 x/menit
Irama jantung normal
Kadar Elektrolit Na
<135 meq, K 3,5 4,5
meq, BUN,U/C, HCT
dalam batas normal
Osmolaritas plasma
normal/turun
ANALISA
Volume cairan
elektrolit lebih
kebutuhan
PERENCANAAN
EVALUASI
Jam :
dan Mandiri
Subyektif :
dari
1. Atur posisi semi fowler 45 derajat
...................................
2. Pantau Berat badan .tiap..................................................
...................................
3. Kaji suara nafas tiap........................................................
4. Kaji membran mukosa dan turgor kulit
...................................
tiap jam
...................................
5. Pasang IV line dan Dower kateter
...................................
6. Pantau intake dan output tiap jam....................................................................
.......................................................................................
...................................
7. Monitoring EKG tiap.....................................................
Obyektif :
8. Monitoring CVP / PCWP tiap .....................................
...................................
.......................................................................................
...................................
9. Kaji tanda edema periver tiap ......................................
...................................
......................................................................................
...................................
Kolaborasi
...................................
10. Batasi cairan sesuai order dokter...................................
...................................
........................................................................................
11. Berikan terapi oksigen......................................................................................
Assesment :
.........................................................................................
12. Berikan obat inotropik dan vasodilator sesuai order ...................................
dokter................................................................................................................
..........................................................................................................................
13. Berikan diuretik ( Furosemid, manitol,
...................................
Diamox, spironolacton).................................................
...................................
.......................................................................................
Planning :
14. Berikan koreksi kekurangan atau kelebihan
...................................
kadar elektrolit...............................................................
...................................
.......................................................................................
...................................
.......................................................................................
...................................
15. lakukan pemeriksaan kadar serum elektrolit, BUN, U,C,
...................................
HCT, Berat jenis plasma
urine tiap.......................................................................
...................................
16. Pantau BGA tiap ............................................................
...................................
17. Pantau osmolalitas plasma tubuh tiap...................... ..................................
GL/
AM
NO.
DX
7
SUBYEKT
IF
OBYEKTIF
ANALISA
Perubahan perfusi
Ada distress nafas
jaringan
( Kelelahan, kesadaran
(cardiopulmonary)
menurun, dipsnea,
tachipnea, bradipnea,
apnea, retraksi
otot dada, PCH, sianosis)
RR > 25 x/menit
Whezzing positif
Ronchii positif
Ada chest pain
SBP < 90 mmHg
DBP < 60 mmHg
Nadi > 120 x/menit
Cardiac output turun ditandai
( PU < 0,5-1 ml/kg/jam,
kesadaran turun , perfusi dingin
)
Ekspansi paru tidak adequate
Foto thorax menunjukan ada
tanda infiltrate.
PERENCANAAN
EVALUASI
Mandiri
Jam :
1. Monitoring TTV tiap shift
Subyektif :
2. Monitoring RR, pola nafas dan suara nafas
...................................
Tiap shift
...................................
3. Monitoring CVP,PCWP, PAP dan CO ...................................
tiap.
...................................
...................................
...................................
.
...................................
4. Pertahankan cardiac monitor, dan
Obyektif :
dokumentasikan adanya disritmia .
...................................
5. Kaji EKG untuk identifikasi disritmia ...................................
tiap.
...................................
...................................
...................................
.
...................................
6. Monitoring suara jantung
...................................
tiap.
Assesment :
...................................
...................................
.
...................................
7. Lakukan tindakan yang meningkatkan ...................................
Venous return,
...................................
Misal : tinggikan kaki bila ada hipotensi
Planning :
8. Kaji adanya chest pain,
...................................
berikan intervensi bila ada
...................................
Kolaborasi
...................................
9. Pertahankan pemberian obat vasopressor
...................................
untuk meningkatkan tekanan darah sesuai
...................................
order
...................................
Dokter : ........................................................
...................................
..................
..................................
L/
M
.......................................................................
.................
..............................................................
SUBYEKTIF
OBYEKTIF
SBP < 90 mmHg
DBP < 60 mmHg
CPP < 60 mmHg
ICP > dari 20 mmHg
MAP < 70 atau > 120
mmHg
Temperatur > 37,5 derajat
Pola nafas tidak normal
( sebutkan jenisnya :
ataksis, bradipnea,
tachipnea, cyanostokes
dll )
Ada tanda tanda
peningkatan TIK
( pusing, kejang,
muntah,mual, pupil
aniisokor dll )
Ada penurunan kesadaran
Ada penurunan GCS
Ada kejang
Ada lateralisasi
ANALISA
Perubahan
perfusi
cerebri
PERENCANAAN
EVALUA
Mandiri
Jam :
1. Atur posisi head up 30 45 derajat
Subyektif :
2. Monitoring BP, RR, Temperatur, Nadi, Saturasi oksigen tiap jam
............................
3. Laporkaan jika ada perubahan pola
............................
nafas dan kenaikan tekanan darah
............................
4. Hindari kepala dan leher terlalu
............................
hiperfleksi atau hiperekstensi
............................
5. Jaga lingkungan tenang
............................
6. Kurangi intervensi perawatan yang
............................
terlalu sering merangsang kenaikan tekanan intracranial
Obyektif :
Misalnya : suctioning
............................
7. Berikan sedasi sebelum sutioning...................................
............................
.........................................................................................
............................
8. Hindari kepala dan leher terlalu
............................
rotasi untuk mencegah return blood flow dari kepala ke jantung
............................
9. Pertahankan suhu normal
............................
10. Waspada adanya herniasi :
............................
Kenaikan tekanan darah,
Assesment :
kenaikan tekanan nadi,
............................
bradicardia, pusing, muntah,
............................
papilodema, perubahan ukuran
............................
pupil dan anisocor.
............................
11. Cegah terjadinya konstipasi
............................
12. Dokumentasikan status neurologi dan bandingkan dengan dengan data dasar/awal
Planning :
13. Laporkan bila ada penurunan kesadaran
............................
Kolaborasi
............................
14. Berikan terapi oksigen.....................................................
............................
.........................................................................................
............................
15. Pemberian Medikasi .......................................................
............................
.........................................................................................
............................
GL/
AM
............................
............................
Diagnosa Medis
:
No. RM
:
Tanggal pengkajian :
NO.
DX
9
SUBYEKTIF
OBYEKTIF
Ekstrimitas dingin
pucat
Sianosis periver
Kesadaran
menurun
Capilari reffil > 2
detik
Allen test > 2 detik
ANALISA
Perubahan perfusi
jaringan periver
PERENCANAAN
EVALUASI
Mandiri
Jam :
1. Memonitor TTV tiap shift
Subyektif :
2. Mngkaji kwalitas denyut nadi tiap shift
...................................
3. Mengkaji temperatur, warna dan textur
...................................
Kulit tiap ..........................................................................
...................................
4. Memantau suhu tubuh, bila terjadi
...................................
peningkatan atau penurunan segera
...................................
lakukan intervensi.............................................................
...................................
..........................................................................................
...................................
5. Mengaji penyebab vasokontriksi akibat pengunaan Obyektif :
obat obatan vasopressor :.................................................
...................................
..........................................................................................
...................................
.........................................................................................
...................................
6. Menghindari tekanan yang terlalu
...................................
lama pada ekstrimitas dan daerah yang
...................................
tertekan
...................................
7. Memantau capilary reffill tiap
...................................
.
Assesment :
...................................
8. Memantau allen test tiap
...................................
...................................
...................................
Kolaborasi
...................................
9. Menkaji mixed BGA tiap .
Planning :
..
...................................
................................................................................. ...................................
................................................................................. ...................................
................................................................................. ...................................
................................................................................. ...................................
................................................................................. ............................................
GL/
AM
.................................................................................
.................................................................................
.......................................................................
CATATAN PERKEMBANGAN (DX 10 ) GANGGUAN RASA NYAMAN NYERI
Diagnosa Medis
:
No. RM
:
Tanggal pengkajian :
NO.
DX
10
SUBYEKTIF
OBYEKTIF
ANALISA
PERENCANAAN
EVALUASI
Mandiri
Jam :
1. Kaji perasaan nyeri (P,Q,R,S,T ) tiap ..........
Subyektif :
......................................................................
...................................
2. Kaji skala nyeri tiap ....................................
...................................
3. Tinggikan bagian yang nyeri/sakit
...................................
4. Atur posisi yang nyaman
...................................
5. Jaga lingkungan tenang
...................................
6. Beritahu setiap prosedur yang akan dilakukan
...................................
7. Penatalaksanaan stress seperti nafas dalam, tehnik
...................................
relaksasi, distraksi
Obyektif :
8. Berikan terapi non farmakologi mengatasi
...................................
nyeri : Guided Imagery, effleurage, kompres
hangat
...................................
dingin)
...................................
9. Batasi aktifitas pencetus nyeri
...................................
10. Bantu ADL
...................................
11. Beri dukungan dan diskusi tentang
...................................
masalah nyeri
...................................
Assesment :
Kolaborasi
...................................
12. Beri Analgesik dan sedasi/ managemen
...................................
nyeri........................................................................ ...................................
.........
...................................
................................................................................. ...................................
........
Planning :
................................................................................. ...................................
........
...................................
................................................................................. ...................................
........
...................................
................................................................................. ...................................
........
............................................
GL/
AM
.................................................................................
........
.....................................................................
SUBYEK
TIF
OBYEKTIF
ANALISA
Perubahan
perfusi
jaringan bd
penurunan
volume
darah
PERENCANAAN
Mandiri
1. Kaji TTV, warna kulit, temperatur,
capilary refill, level kesadaran,status neurology tiap shift.
2. Kaji irama jantung tiap.
3. Kaji keseimbangan intake dan output tiap jam
4. Kaji Berat badan tiap hari.
5. Kaji jumlah dan tipe drainage yang dikeluarkan dari
Luka, drain thorax, NGT dan
redon drain tiap.
6. Kaji PU tiap jam
7. Pertahankan airway : ......................................................
8. Pasang torniquet untuk
menghentikan perdarahan
9. Pasang dower kateter
10. Atur posisi supine, trnederlenburg
11. Berikan support moral pada pasien /keluarga
Kolaborasi
12. Pasang IV line, berikan nomer cateter IV line ukuran besar.
13. Ambil sample darah.
14. Berikan resusitasi cairan mengunakan kristaloid, plasma
ekspnder, Koloid dan
darah.:..............................................................
15. Berikan cairan yang hangat.
16. Berikan oksigen terapi....................................................
17. Berikan vasoaktif ...........................
18. Berikan alangesik dan berikan rasa nyaman
19. Berikan antibiotik profilaksis..........................................
20. Kolaborasi pemberian diet untuk memenuhi kebutuhan
nutrisi perhari..................................................................
EVALUASI
Jam :
Subyektif :
...................................
...................................
...................................
...................................
...................................
...................................
...................................
Obyektif :
...................................
...................................
...................................
...................................
...................................
...................................
...................................
Assesment :
...................................
...................................
...................................
...................................
...................................
Planning :
...................................
...................................
...................................
...................................
...................................
GL/
AM
.....................................
SUBYEK
TIF
OBYEKTIF
Aktifitas menurun
Tidak bisa makan
Tidur pakai bantal tinggi
SBP < 90 mmHg
DBP < 60 mmHg
Nadi > 120x/menit
Irama jantung sinus
tachicardia atau tanda gagal
jantung
Ada chest pain
Ada edema
Asites
JVD meningkat
Whezzing negatif
Ronchii positif
Ada tanda penurunan
cardiac output
( BP turun, HR naik, PU
turun, Kelelahan,
Kelemahan, dingin, pucat,
kulit lembab )
Ada distress nafas
( Kelelahan, kesadaran
menurun, dipsnea,
tachipnea, bradipnea,
apnea, retraksi
otot dada, PCH, sianosis)
ANALISA
Penurunan
cardiac output
PERENCANAAN
Mandiri
1. Istirahatkan / bedrest
2. Pertahankan lingkungan tenang,
3. Jaga keseimbangan istirahat dan aktifitas
4. Kaji tanda tanda dan gejala penurunan cardiac output
( BP turun, HR naik, PU
turun, Kelelahan, Kelemahan, dingin, pucat, kulit lembab )
tiap..................................................................
5. Monitoring BP, Nadi apikal, temperatur, RR dan saturasi oksigen
tiap........................................................
6. Auskultasi bunyi nafas tiap ............................................
7. Kaji adanya SOB dan Chest pain tiap.............................
8. Auskultasi bunyi jantung S3,S4 tiap..............................
9. Berikan tindakan yang meningkatkan CO, mengurangi beban
jantung : ...............................................................
10. Monitoring PAP, PCWP, CVP.tiap................................
11. Kaji EKG 12 lead tiap ...................................................
12. Pantau intake dan output tiap shift
13. Hindari tindakan yang menimbulkan valsava manuver (mengejan,
batuk), dengan memberikan laxadine, diet tinggi serat
14. Pertahankan IV line
Kolaborasi
15. Berikan terapi oksigen sesuai order
dokter..............................................................................
16. Berikan medikasi dan observasi respon pemberiannya
( Nitrat, Beta blokker, Ca blokker, Antiaritmia, antikoagulan,
digitalis, furosemid, dopamin, dobutamin, digitalis, Nor epinefrin
dansedasi)...................................................................
17. Monitoring nilai laboratorium ( Kadar elektrolit, Kolesterol,
LDL,HDL, CKMB, SGOT,SGPT, Enzim otot jantung, LDH dan
EVALUAS
Jam :
Subyektif :
...............................
...............................
...............................
...............................
...............................
...............................
...............................
Obyektif :
...............................
...............................
...............................
...............................
...............................
...............................
...............................
Assesment :
...............................
...............................
...............................
...............................
...............................
Planning :
...............................
...............................
...............................
...............................
GL/
AM
...............................
...............................
..
SUBYEKTIF
OBYEKTIF
Terdapat
kontraktur,
Kerusakan kulit
: Ulcus
decubitus,
Footdrop dan
Deep Vein
Trombosis.
Tidak dapat
mengerakan
kaki dan tangan
Kekuatan otot
ekstrimitas
5/5
5/5
ANALISA
Kerusakan mobilitas
fisik berhubungan
dengan kerusakan
neuromusculer
PERENCANAAN
EVALUASI
...................................
.
Planning :
.
...................................
...................................
...................................
...................................
...................................
............................................
GL/
AM
NO.
DX
14
8.00
SUBYEK
TIF
OBYEKTIF
ANALISA
Pasien
bedrest Resiko tinggi
lama
kerusakan
Mengalami
integritas kulit
penurunan
kesadaran
Pasien
mengalami
dficit neurologi
Pasien
mengalami
parese atau plegi
pada ke empat
ekstrimitasnya
Odema anasarka
BAB dan BAK
tidak
bisa
dikontrol
Hipotensi
Status
nutrisi
jelek
PERENCANAAN
EVALUA
Mandiri
Jam :
1. Mengkaji integritas kulit terutama pada daerah yang tertekan
Subyektif :
2. Mempertahankan kulit tetap bersih dan kering
............................
3. Memantau adanya iritasi pada kulit
............................
4. Memberikan krem pelembab
............................
5. Mobilisasi pasien tiap 2 jam
............................
6. Memasang matras antidecubitus
............................
7. Memberikan masage pada area yang tertekan,kemerahan pada setiap
............................
perubahan posisi
............................
8. Membantu latihan gerak pasive dan aktif
Obyektif :
9. Memantau asupan kalori yang telah dikonsumsi
............................
10. Melindungi kulit dari kontaminasi urine, feses, plester dan perpirasi yang ............................
berlebihan.
............................
11. Mengunakan sabun yang lembut dan tidak mengandung alkohol
............................
12. Memberi pakaian yang lembut, tidak ketat, hindari pengunaan kancing ............................
yang terlalu besar dan berada di daerah yang tertekan
............................
13. Memberikan pengaman /padding pada elbow, tumit atau sacrum
............................
14. Hati hati pada waktu pergantian posisi, pergantian linen
Assesment :
Kolaborasi
............................
15. Memantau nila laboratorium yang berpengaruh
............................
pada integritas kulit seperti :
............................
albumin, hemoglobin, hematokrit, asam urat, BUN,
............................
bilirubin ,gula darah dan BGA tiap.........................................
............................
16. Kolaborasi dengan dokter dan ahli gizi menentukan jumlah kalori dan
Planning :
prosedur pemberiannya
............................
17. Menentukan jenis diet yang memenuhi
............................
kebutuhan protein, cairan dan kalori...............................
............................
............................
............................
GL/
AM
............................
....
CATATAN PERKEMBANGAN (DX 15 ) RESIKO TINGGI INFEKSI PARU BD PEMAKAIAN ARTIFISIAL AIRWAY, VENTILATOR
Diagnosa Medis
:
No. RM
:
Tanggal pengkajian :
NO.
DX
14
SUBYEKTIF
OBYEKTIF
Sputum
purulenta,
Berbau
Produksi
sputum banyak
Kultur kuman
positif
AdaDistress
nafas
Nyeri pleuritic
Sulit weaning
dari ventilator
Leukositosis
Demam
ANALISA
Resiko tinggi infeksi
paru bd pemakaian
artifisial airway,
ventilator
PERENCANAAN
EVALUASI
Mandiri
Jam :
1. Monitor temperatur tiap ................................
Subyektif :
2. Minitoring jumlah, produksi, bau,
...................................
consistensi sputum tiap ....................................
...................................
.........................................................................
...................................
3. Lakukan hand washing sebelum melakukan
...................................
tindakan pada pasien
...................................
4. Pakai sarung tangan setiap pelaksanaan
...................................
prosedur, terutama pada waktu suctioning
...................................
Sputum
Obyektif :
5. Gunakan tehnik steril pada pelaksanaan suctioning sputum
...................................
6. Atur posisi head up 45 derajat
...................................
7. Ganti tubing , ETT, Trcheo canule tiap 7 hari
...................................
8. Lakukan kultur sputum
...................................
9. Lakukan kultur pada alat bantu nafas
...................................
10. Pasang nasogastric tube pada pasien yang terpasang
...................................
ventilator mekanik
...................................
Assesment :
Kolaborasi
...................................
11. Pemberian antibiotik ......................................................
...................................
........................................................................................
...................................
..........................................................................................................................
..........................................................................................................................
.......................................................................................Planning :
..........................................................................................................................
12. Pemberian Medikasi lain
...................................
........................................................................................
...................................
........................................................................................
...................................
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...................................
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