NEURO 1

SKENARIO
TUTORIAL IPE 2

EVIDENCE BASED
MEDICINE
Keywords: Children, cold water sponging, fever, paracetamol, temperature.

2013
P: Fever
Sample: 88 anak usia 1-10 th.

I:
Kelompok CWS
Pengukuran TPR. Subjek penelitian dimandikan dari kepala-kaki
oleh ibu mereka, pengasuh ataupun asisten peneliti. Sponging
dilakukan selama 30 menit.

Kelompok Paracetamol
Diberikan paracetamol dengan dosis 15mg/kg BB, sedangkan
pengamatan lainnya seperti yang diberikan pada kelompok CWS
seperti TPR.
 O:
Hyperthermia r/t Infection Factor
NOC (Nursing Outcomes Classification)

Mempertahankan suhu dalam kisaran normal (5)

Menjelaskan tindakan yang diperlukan untuk menjaga suhu
normal (5)
mengobati hipertermia (5)
NIC (Nursing Interventions Classification)

1. Menganjurkan untuk meningkatkan cairan untuk mencegah

hipertermia dan dehidrasi yang disertai demam.

Pinto, S., Walsh, K., Heart stroke. CINAHL Information Systems, Dec 23, 2011 (2p)
http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=40ac8537-a3d4-4e3b-b632-
5214cbd9402d%40sessionmgr11&vid=12&hid=21
 Intervensi

2. Menganjurkan klien untuk tinggal di lingkungan yang

sejuk.

Beard, R.M., Day, M.W. Fever and hyperthermia: learn to beat the heat. Nursing. 2008;38(6):2831.

Centers for Disease Control and Prevention (CDC), Heat stress, 2012 NIOSH workplace safety and
health tips. Retrieved September 3, 2012, from http://www.cdc.gov/niosh/topics/heatstress, 2012.
3. Perhatikan perubahan tanda-tanda vital yang terkait dengan
hipertermia: cepat nadi; peningkatan laju pernafasan; dan
penurunan tekanan darah, serta tanda dan gejala dehidrasi.

Dinarello, C.A., Porat, R. Fever and hyperthermia. In Longo D.L., et al, eds.: Harrisons principles
of internal medicine, ed 18, New York: McGraw-Hill, 2011.
Becker, J.H., Wu, S.C. Fever: an update. J Am Podiatr Med Assoc. 2010;100(4):281290.

4. Pantau klien untuk tanda-tanda hipertermia (mis., Sakit kepala, mual

dan muntah, lemah, tidak berkeringat, delirium, dan koma).
 OUTCOME
S : Pasien mengatakan tidak merasa hipertermi

O:
Suhu dalam kisaran normal (5)
Mengetahui tindakan yang diperlukan untuk menjaga suhu
normal (5)
mengobati hipertermia (5)

A : Masalah teratasi.
P : Hentikan intervensi.
 Ineffective Airway Clearance r/t
Obstructed Airway (Excessive Mucus)

NOC (Nursing Outcomes Classification)

Batuk efektif dan suara nafas jernih (5)

Jalan napas paten (5)
Jelaskan metode untuk meningkatkan pembuangan
sekresi (5)
Jelaskan pentingnya perubahan sputum (warna,
karakter, jumlah, dan bau) (5)
NIC (Nursing Interventions Classification)
1. Auskultasi suara napas.
Rasional: Breath sounds are normally clear or a few scattered fine crackles
at bases, which clear with deep breathing. The presence of coarse crackles
during inspiration indicates fluid in the airway; wheezing indicates an airway
obstruction (Jarvis, C. Physical examination and health, ed 6. St Louis: Elsevier Saunders; 2012).

2. Amati dahak, dari warna, bau, dan volume.

Rasional: Normal sputum is clear or gray and minimal; abnormal sputum is
green, yellow, or bloody; malodorous; and often copious. The presence of
purulent sputum during a COPD exacerbation can be sufficient indication
for starting empirical antibiotic treatment. Notify physician of purulent
sputum (GOLD. Global strategy for the diagnosis, management, and prevention of COPD (revised 2011). Global
Initiative for Chronic Obstructive Lung Disease; 2011).
 Intervensi

3. Membantu klien bernafas dalam-dalam dan melakukan batuk

efektif.
Rasional: Controlled coughing uses the diaphragmatic muscles,
making the cough more forceful and effective (Gosselink, R., et al.
Physiotherapy for adult patients with critical illness: recommendations
of the European respiratory society and European society of critical
care medicine task force on physiotherapy for critically ill patients.
Intensive Care Med. 2008;34:11881199).
 Intervensi

4. Memposisikan klien untuk mengoptimalkan respirasi .

Rasional: An upright position allows for maximal lung expansion; lying flat
causes abdominal organs to shift toward the chest, which crowds the
lungs and makes it more difficult to breathe. EB: In a mechanically
ventilated client, there is a decreased incidence of ventilatorassociated
pneumonia if the client is positioned at a 30-to 45-degree
semirecumbent position as opposed to a supine position.

Vollman, K., Sole, M. Endotracheal tube and oral care. In Lynn-McHale D.J., ed.: AACN procedure manual for critical care,
ed 6, Philadelphia: Saunders Elsevier, 2011.

Siela, D. Evaluation standards for management of artificial airways. Crit Care Nurse. 2010;30(4):7678.
 OUTCOME
S : Pasien mengatakan jalan napasnya menjadi lancar.
O : Batuk efektif dan suara nafas jernih 5
Jalan napas paten 5
Mengetahui metode untuk meningkatkan pembuangan sekresi 5
Warna, karakter, jumlah, dalam batas normal 5
A : Masalah teratasi.
P : Hentikan intervensi.