Daftar Isi Cover Kata Pengantar........................................ Pengantar............................................................... .............................................. ............................................................ii .....................................ii Daftar Isi............................................... Isi...................................................................... .............................................. ............................................................. ...................................... iii BAB I PENDAHULUAN............................ PENDAHULUAN................................................... .............................................. .......................................................1 ................................1 A. Latar Belakang...............................................................................................................................1
B. Rumusan Masala .........................................................................................................................2 C. !u"uan Penulisan ...........................................................................................................................2 1. !u"uan Umum ............................................................................................................................2 #. !u"uan Kusus ...........................................................................................................................2
BAB II !IN$AUAN PU%!AKA.................. PU%!AKA......................................... .............................................. .......................................................& ................................& A. Konse' Dasar Bron(o'neumonia........ Bron(o'neumonia............................... .............................................. .............................................. ....................................& .............& 1. Defnisi...........................................................................................................................................3
#. Etiologi..........................................................................................................................................3 &. Patofisiologi ...................................................................................................................................4 ). *e"ala Klinis.................................................................................................................................6 +. Pemeri(saan Penun"ang .................................................................................................................6 ,.
Penatala(sanaan.........................................................................................................................7
B. Asuan Ke'era-atan Dengan BP Paa Ana(...................................... Ana(............................................................. ................................../ .........../ Air-a0 Management...................... Management............................................. .............................................. .............................................. ............................................1& .....................1& Air-a0 Management...................... Management............................................. .............................................. .............................................. ............................................1, .....................1, Res'irator0 Monitoring..................................... Monitoring............................................................ .............................................. ................................................1 .........................1 BAB III PENU!UP.............................. PENU!UP..................................................... .............................................. .............................................. ......................................#& ...............#& A.
Kesim'ulan..............................................................................................................................23
B.
%aran........................................................................................................................................23
DA2!AR PU%!AKA
BAB I PENDAHULUAN A. Latar Belakang Ana(3a Ana(3ana( na( sangat sangat rentan rentan tera teraa' a' 4er4ag 4er4agai ai 'en0a( 'en0a(it it 0ang 0ang 4isa 4isa ise4a ise4a4(a 4(an n ole ole (uma (uman5 n5 viru virus5 s5 an an mi(r mi(roo oorg rgan anism ismee lain lain.. 2a(t 2a(tor or ling ling(u (ung ngan an meru meru'a 'a(a (an n sala sala satu satu 'en0e4a4n0a. Ana( sangat su(a 4ermain i alam atau'un i luar ruma seingga 'erlu mem'er mem'erat ati(a i(an n ling(u ling(unga ngan n i se(ita se(itarr ana(. ana(. Pen0a( Pen0a(it it 0ang 0ang sering sering te"ai te"ai 'aa 'aa ana( ana( 0aitu 0aitu 'en0a(it 'aa saluran 'ernafasan. %ala satu 'en0a(it saluran 'ernafasan 'aa ana( aala 4ron(o'neumonia. Di negara ma"u 'en0a(it ini 4an0a( itemu(an. %elain itu5 i negara 4er(em4ang "uga 4an0a( itemu(an itemu(an an 'en0a(it ini meru'a(an 'en0a(it 0ang men0e4a4(an men0e4a4(an (ematian 'aa ana( usia 6 sam'ai , taun. Bron(o Bron(o'ne 'neumo umonia nia 'roses 'roses inflam inflamasi asi 'aru 'aru 0ang 0ang umumn0 umumn0aa ise4a ise4a4(a 4(an n ole ole agens agens infe(sius5 infe(sius5 serta mengam4ar( mengam4ar(an an 'neumonia 'neumonia 0ang mem'un0ai mem'un0ai 'ola 'en0enaran 4er4er7a(5 alam satu atau le4i area terlo(alisasi terlo(alisasi alam 4ron(iolus 4ron(iolus an meluas meluas (e'eren(im (e'eren(im 'aru 0ang tere(at 8Nursalam5 #66+9. Pen0a( Pen0a(it it 4ron(o 4ron(o'ne 'neumo umonia nia i Inone Inonesia sia 4eraa 4eraa i 'osisi 'osisi (eela (eela'an 'an ari ari se'ulu se'ulu 'en0a(it 0ang ira-at i Ruma %a(it i seluru Inonesia setela iare5 emam 4erara engue engue55 ti'oi ti'oi55 emam emam 'e0e4a 'e0e4a4n0 4n0aa tia( tia( i(eta i(etaui5 ui5 s0'e' s0'e'sia sia55 i'erte i'ertensi nsi55 I%PA. I%PA. Peran Peran 'era-at alam mela(u(an asuan (e'era-atan 'aa ana( engan 4ron(o'neumonia meli'uti usaa 'romotif 0aitu engan selalu men"aga (e4ersian 4ai( fisi( mau'un ling(ungan5 u'a0a 'reventif ila(u(an engan 7ara mem4eri(an o4at sesuai engan ini(asi 0ang i an"ur(an ole ole o(t o(ter er55 an an u'a0 u'a0aa (ura (urati tiff 'era 'era-a -att ala alam m memu memuli li( (an an (on (onis isii (lie (lien n eng engan an mengan"ur(an orang tua (lien unut( mem4a-a (e ruma sa(it. Hal ini ila(u(an untu( mening(at(an era"at (eseatan (lien.
1
B. Rumusan Masalah
1. A'a(a efinisi ari 4ron(o'neumonia: #. A'a sa"a etiologi ari 4ron(o'neumonia: &. Bagaimana(a 'atofisiologi ari 'en0a(it 4ron(o'nrumonia: ). A'a sa"a(a tana an ge"ala 'aa 'en0a(it 4rom(o'neumonia: +. A'a sa"a 'emeri(saan 'enun"ang 0ang ila(u(an 'aa 'en0a(it 4ron(o'neumonia: ,. Bagaimana(a 'enatala(sanaan 'aa 'en0a(it 4ron(o'neumonia:
C. Tujuan Penulisan 1. Tujuan Umum
Mam'u memaami masala 4ron(o'neumonia 'aa 4a0i an ana( engan menera'(an asuan (e'era-atan 0ang te'at. 2. Tujuan husus
a. Mam'u men"elas(an tentang 'engertian ari 4ron(o'neumonia 4. Mam'u men"elas(an tentang etiologi ari 4ron(o'neumonia 7. Mam'u men"elas(an tentang 'atofisiologi ari 4ron(o'neumonia . Mam'u men"elas(an tentang ge"ala (linis ari 4ron(o'neumonia e. Mam'u men"elas(an tentang 'emeri(saan 'enun"ang ari 4ron(o'neumonia f. Mam'u men"elas(an tentang 'enatala(sanaan ari 4ron(o'neumonia g. Mam'u men"elas(an tentang asuan (e'rra-atan engan 'asien 4a0i an ana( 0ang mengalami ari 4ron(o'neumonia
2
BAB II TIN!AUAN PU"TAA
A. #nse$ Dasar Br#n%#$neum#nia 1. Definisi Bron(o'neumoni aala sala satu "enis 'neumonia 0ang mem'un0ai 'ola 'en0e4aran 4er4er7a(5 teratur alam satu atau le4i area terlo(alisasi i alam 4ron(i an meluas (e 'aren(im 'aru 0ang 4ere(atan i se(itarn0a.8%melt;er < %u;anne C5 #66# = +#9. Bron(o'neumonia meru'a(an 'eraangan 'aa 'aren(im 'aru 0ang ise4a4(an ole 4a(teri5 virus5 "amur5 atau'un 4ena asing 0ang itanai engan ge"ala 'anas 0ang tingggi gelisa5 i'snea nafas 7e'at an ang(al5 munta5 iare serta 4atu( (ering an 'rou(tif. Bron(o'neumoni aala suatu 'eraangan 'aru 0ang 4iasan0a men0erang i 4ron(eoli terminal. Bron(eoli terminal tersum4at ole e(suat mo(o'urulen 0ang mem4entu( 4er7a(34er7a( (onsoliasi i lo4uli 0ang 4ere(atan. Pen0a(it ini sering 4ersifat se(uner5 men0ertai infe(si saluran 'ernafasan atas5 emam infe(si 0ang s'esifi( an 'en0a(it 0ang melema(an a0a taan tu4u. Kesim'ulann0a 4ron(o'neumoni aala "enis infe(si 'aru 0ang ise4a4(an ole agen infe(sius an tera'at i aera 4ron(us an se(itar alveoli.
2. Eti#l#&i %e7ara
umum
4ron(o'neumoni
ia(i4at(an
'enurunan
me(anisme
'ertaanan tu4u teraa' virulensi organisme 'antogen. >rang normal an seat mem'un0ai me(anisme 'ertaanan tu4u teraa' organ 'ernafasan 0ang teriri atas = refle( glotis an 4atu(5 aan0a la'isan mu(us5 gera(an silia 0ang menggera((an (uman (eluar ari organ5 an se(resi umoral setem'at. !im4uln0a 4ron(o'neumoni ise4a4(an ole virus5 4a(teri5 "amur5 'roto;oa5 mi(o4a(teri5 mi(o'lasma5 an ri(etsia. 8 %anra M. Nettiria5 #661 = ,?# 9 Antara lain = 1. Ba(teri = stre'to7o77us5 %ta'0lo7o77us5 H. Influen;ae5 Kle4siella. #. @irus = legionella 'neumoniae 3
&. $amur = as'ergillus s'esies5 7ania al4i7ans5 ito'lasma ). As'irasi ma(anan5 se(resi orofaringeal atau isi lam4ung (e alam 'ari3'aru +. !er"ai (arena (ongesti 'aru 0ang lama
'. Pat#fisi#l#&i Bron7o'neumonia selalu iaului ole infe(si saluran nafas 4agian atas 0ang ise4a4(an ole 4a(teri sta'0lo7o77us5 Haemo'illus influen;ae atau (arena as'irasi ma(anan an minuman.Dari saluran 'ernafasan (emuian se4agian (uman terse4ut masu(l (e saluran 'ernafasan 4agian 4a-a an men0e4a4(an ter"ain0a infe(si (uman i tem'at terse4ut5 se4agian lagi masu( (e 'em4ulu ara an menginfe(si saluran 'ernafasan engan gan4aran se4agai 4eri(ut= 1. Infe(si saluran nafas 4agian 4a-a men0e4a4(an tiga al5 0aitu ilatasi 'em4ulu ara alveoli5 'ening(atan suu5 an eema antara (a'iler an alveoli. #. E(s'ansi (uman melalui 'em4ulu ara (emuian masu( (e alam saluran 'en7ernaan an menginfe(sin0a menga(i4at(an ter"ain0a 'ening(atan flora normal alam usus5 'eristalti( mening(at a(i4at usus mengalami mala4sor4si an (emuian ter"aila iare 0ang 4eresi(o teraa' gangguan (eseim4angan 7airan an ele(trolit. 8%oe'arman5 1//19
Pat-a0 4
5
(. )ejala linis Bron(o'neumonia 4iasan0a iaului ole suatu infe(si i saluran 'ernafasan 4agian atas selama 4e4era'a ari. Paa taa' a-al5 'enerita 4ron(o'neumonia mengalami tana an ge"ala 0ang (as se'erti menggigil5 emam5 n0eri aa 'leuritis5 4atu( 'rou(tif5 iung (emeraan5 saat 4ernafas mengguna(an otot a(sesorius an 4isa tim4ul sianosis 8Bar4ara C. long5 1//, = )&+9. !erengar aan0a (re(els i atas 'aru 0ang sa(it an terengar (eti(a ter"ai (onsoliasi 8'engisian rongga uara ole e(suat9 8 Pri7e an ilson5 #66,9. !ana ge"ala 0ang mun7ul 'aa 4ron(o'neumonia aala= a. Kesulitan an sa(it 'aa saat 'ernafasan 19 N0eri 'leuriti( #9 Nafas ang(al an meneng(ur &9 !a(i'nea 4. Bun0i nafas i atas area 0ang menglami (onsoliasi 19 Menge7il5 (emuian men"ai ilang #9 Kre(els5 ron(i5 7. . e. f. g. .
*era(an aa tia( simetris Menggigil an emam &?5? C sam'ai )151C5 elirium Diafoesis Anore(sia Malaise Batu( (ental5 'rou(tif %'utum (uning (ei"auan (emuian 4eru4a men"ai (emeraan atau 4er(arat i. *elisa ". %ianosis Area sir(umoral5 asar (u(u (e4iruan (. Masala3masala 'si(ososial = isorientasi5 ansietas5 ta(ut mati 8Martin tu7(er5 %usan. #666#)9.
*. Pemeri%saan Penunjan& Untu( a'at menega((an iagnosa (e'era-atan a'at iguna(an 7ara= a. Pemeri(saan La4oratorium 1.
#.
Pemeri(saan ara Paa (asus 4ron(o'neumonia ole 4a(teri a(an ter"ai leu(ositosis 8mening(atn0a "umla neutrofil9. 8%anra M. Nettina5 #661 = ,?)9 Pemeri(saan s'utum Baan 'emeri(saan 0ang ter4ai( i'erole ari 4atu( 0ang s'ontan an alam. Diguna(an untu( 'emeri(saan mi(ros(o'is an untu( (ultur serta tes sensitifitas untu( menete(si agen infe(sius. 8Bar4ara C5 Long5 1//, = )&+9 6
&. ). +.
Analisa gas ara untu( mengevaluasi status o(sigenasi an status asam 4asa. 8%anra M. Nettina5 #661 = ,?)9. Kultur ara untu( menete(si 4a(teremia %'utum5 an urin untu( tes imunologi untu( menete(si antigen mi(ro4a 8%anra M. Nettina5 #661 = ,?)9.
4. Pemeri(saan Raiologi 1.
Rontgenogram !ora(s Menun"u((an (onsoliasi lo4ar 0ang sering(ali i"um'ai 'aa infe(si 'neumo(o(al atau (le4siella. Infiltrat multi'le sering(ali i"um'ai 'aa infe(si
2.
stafilo(o(us an aemofilus 8Bar4ara C5 Long5 1//, = )&+9. Laringos(o'i 4ron(os(o'i untu( menentu(an a'a(a "alan nafas tersum4at ole 4ena 'aat 8%anra M5 Nettina5 #6619.
+. Penatala%sanaan
Penatala(sanaan Ke'era-atan 0ang a'at i4eri(an 'aa (lien 4ron(o'neumonia aala= a. 4.
7.
Men"aga (elan7aran 'erna'asan Ke4utuan istiraat Pasien ini ssering i'er'ire(sia ma(a 'asien 'erlu 7u(u' istiraat. %emua (e4utuan 'asien arus itolong item'at tiur. Ke4utuan nutrisi an 7airan Pasien 4ron(o'neumonia am'ir selalu mengalami masu(an ma(anan 0ang (urang. %uu tu4u 0ang tinggi selama 4e4era'a ari an masu(an 7airan 0ang (urang a'at men0e4a4(an eirasi. Untu( men7ega eirasi an
. e.
(e(urangan (alori ii'asang infus engan 7airan glu(osa +F an NaCl 65/F. Mengontrol suu tu4u Men7ega (om'li(asi atau gangguan rasa n0aman an n0aman
%ementara Penatala(sanaan meis 0ang a'at i4eri(an aala= a. 4.
>(sigen # litermenit 8sesuai (e4utuan (lien9 $i(a sesa( tia( terlalu e4at5 a'at imulai ma(an e(sternal 4ertaa' melalui
7.
selang nasogastri( engan feeing ri' $i(a se(resi lenir 4erle4ian a'at i4eri(an inalasi engan salin normal an 4eta agonis untu( trans'or mus(usilier.
7
B. Asuhan e$era,atan Den&an BP Pa-a Ana% 1. PEN)A!IAN
a9 Ientitas. Umumn0a ana( engan a0a taan terganggu a(an menerita 'neumonia 4erulang atau tia( a'at mengatasi 'en0a(it ini engan sem'urna. %elain itu a0a taan tu4u 0ang menurun a(i4at KEP5 'en0a(it menaun5 trauma 'aa 'aru5 anestesia5 as'irasi an 'engo4atan anti4ioti( 0ang tia( sem'urna. 49 Ri-a0at Ke'era-atan. 1.
Keluan utama. Ana( sangat gelisa5 is'nea5 'erna'asan 7e'at an ang(al5 iserai 'erna'asan 7u'ing iu'ng5 serta sianosis se(itar iung an mulut. Kaang isertai munta an iare.atau iare5 tin"a 4erara engan atau tan'a lenir5 anore(sia an munta. 8
#.
Ri-a0at 'en0a(it se(arang. Bron(o'neumonia 4iasan0a iaului ole infe(si saluran 'erna'asan 4agian atas selama 4e4era'a ari. %uu tu4u a'at nai( sangat menaa( sam'ai &/3 )66C an (aang isertai (e"ang (arena emam 0ang tinggi.
&.
Ri-a0at 'en0a(it aulu. Perna menerita 'en0a(it infe(si 0ang men0e4a4(an sistem imun menurun.
).
Ri-a0at (eseatan (eluarga. Anggota (eluarga lain 0ang menerita 'en0a(it infe(si saluran 'erna'asan a'at menular(an (e'aa anggota (eluarga 0ang lainn0a.
79 Ri-a0at (eseatan ling(ungan. Menurut ilson an !om'son5 1//6 'neumonia sering ter"ai 'aa musim u"an an a-al musim semi. %elain itu 'emeliaraan (seatan an (e4ersian ling(ungan 0ang (urang "uga 4isa men0e4a4(an ana( menerita sa(it. Ling(ungan 'a4ri( atau 4an0a( asa' an e4u atau'un ling(ungan engan anggota (eluarga 'ero(o(.
9 Imunisasi. Ana( 0ang tia( mena'at(an imunisasi 4eresi(o tinggi untu( mena'at 'en0a(it infe(si saluran 'erna'asan atas atau 4a-a (arena s0stem 'ertaanan tu4u 0ang tia( 7u(u' (uat untu( mela-an infe(si se(uner. e9 Ri-a0at 'ertum4uan an 'er(em4angan. f9 Nutrisi. Ri-a0at gi;i 4uru( atau marasmus 8malnutrisi energi 'rotein G MEP9. g9 Pemeri(saan 'ersistem. 19 %istem (ariovas(uler. !a(i(ari5 irita4ilit0 #9 %istem 'erna'asan. %esa( na'as5 retra(si aa5 mela'or(an ana( sulit 4erna'as5 'erna'asan 7u'ing iung5 ron(i5 -ee;ing5 ta(i'nea5 4atu( 'rou(tif atau non 'rou(tif5 'ergera(an aa asimetris5 'erna'asan tia( teraturireguler5 (emung(inan fri7tion ru45 'er(usi reu' 'aa aera ter"ain0a (onsoliasi5 aa
9
s'utumse(ret. >rang tua 7emas engan (eaaan ana(n0a 0ang 4ertam4a &9
sesa( an 'ile(. %istem 'en7ernaan. Ana( malas minum atau ma(an5 munta5 4erat 4aan menurun5 lema. Paa orang tua 0ang engan ti'e (eluarga ana( 'ertama5 mung(in 4elum memaami
)9
tentang tu"uan an 7ara 'em4erian ma(anan7airan 'ersone. %istem eliminasi. Ana( atau 4a0i menerita iare5 atau eirasi5 orang tua mung(in 4elum memaami alasan ana( menerita iare sam'ai ter"ai eirasi 8ringan
+9
sam'ai 4erat9. %istem saraf. Demam5 (e"ang5 sa(it (e'ala 0ang itanai engan menangis terus 'aa
ana(ana( atau malas minum5 u4un3u4un 7e(ung. ,9 %istem lo(omotormus(ulos(eletal. !onus otot menurun5 lema se7ara umum5 9 %istem eno(rin. !ia( aa (elainan. ?9
%istem integumen. !urgor (ulit menurun5 mem4ran mu(osa (ering5 sianosis5 'u7at5 a(ral angat5
(ulit (ering /9 %istem 'engineraan. !ia( aa (elainan.
2. Dia&n#sa e$era,atan
19
Bersian "alan na'as tia( efe(tif 4. 'ening(atan 'rou(si s'utum
#9
Pola nafas tia( efe(tif 4. i'erventilasi
&9
*angguan 'ertu(aran gas 4. 'eru4aan mem4ran alveolar (a'iler
)9
Risi(o (e(urangan volume 7airan 4eru4ungan engan emam5 menurunn0a inta(e an ta7i'nea
+9
Ke4utuan nutrisi (urang ari (e4utuan tu4u 4. (etia(mam'uan 'emasu(an
atau
men7erna
ma(anan
atau
menga4sor'si
4eru4ungan engan fa(tor 4iologis5 'si(ologis atau e(onomi ,9
Hi'ertermi 4eru4ungan engan aan0a 4a(teri an infe(si virus
'. Interensi e$era,atan
10
;at3;at
gi;i
Dia&n#sa e$era,atan
Tujuan -an riteria
N#
1
Hasil
Bersian "alan nafas tia( N/C 0 efe(tif 4. 'ening(atan a. Res'irator0 status = 'rou(si s'utum @entilation
Interensi NIC 0
Air-a0 su7tion a. Pasti(an (e4utuan oral
4. Res'irator0 status =
tra7eal su7tioning
Air-a0 'aten70 4. Aus(ultasi suara nafas 7. As'iration Control
se4elum an sesua su7tioning. 7. Informasi(an 'aa (lien an
riteria Hasil 0
(eluarga tentang su7tioning
a. Menemonstrasi(an 4atu( efe(tif an suara . Minta (lien nafas alam nafas 0ang 4ersi5 tia(
se4elum su7tion ila(u(an.
aa sianosis an 0s'neu 8mam'u mengeluar(an s'utum5 mam'u 4ernafas engan mua5 tia( aa 'urse li's9
e. Beri(an ># engan mengguna(an nasal untu( memfasilitasi su7tion nasotra(eal . Monitor status o(sigen 'asien
4. Menun"u((an "alan nafas 0ang 'aten 8(lien Air-a0 Management tia( merasa ter7e(i(5 irama nafas5 fre(uensi a. Bu(a "alan nafas5 guana(an te(ni( 7in lift atau "a- trust 'ernafasan alam rentang normal5 tia( aa suara nafas a4normal9
4ila 'erlu 4. Posisi(an 'asien untu( mema(simal(an ventilasi
7. Mam'u mengientifi(asi(an an men7ega fa7tor 0ang a'at mengam4at "alan nafas 11
7. Ientifi(asi 'asien 'erlun0a 'emasangan alat "alan nafas 4uatan e. La(u(an fisiotera'i aa "i(a
'erlu f. Keluar(an se(ret engan 4atu( atau su7tion g. Aus(ultasi suara nafas5 7atat aan0a suara tam4aan l. Monitor res'irasi an status >#
#
Pola nafas tia( efe(tif 4. N/C 0 i'erventilasi a. Res'irator0 status =
NIC 0
Air-a0 Management
@entilation 4.
7.
a. Bu(a "alan nafas5 guana(an
Res'irator0 status =
te(ni( 7in lift atau "a- trust
Air-a0 'aten70
4ila 'erlu
@ital sign %tatus
4. Posisi(an 'asien untu( mema(simal(an ventilasi
riteria Hasil 0
8semi fo-ler an foe-ler9
a. Menemonstrasi(an 4atu( efe(tif an suara 7. Ientifi(asi 'asien 'erlun0a nafas 0ang 4ersi5 tia( 'emasangan alat "alan nafas aa sianosis an 0s'neu 8mam'u mengeluar(an s'utum5 mam'u 4ernafas engan mua5 tia( aa 'urse li's9 4. Menun"u((an "alan nafas 0ang 'aten 8(lien
4uatan e. La(u(an fisiotera'i aa "i(a 'erlu f. Keluar(an se(ret engan 4atu( atau su7tion g. Aus(ultasi suara nafas5 7atat aan0a suara tam4aan
tia( merasa ter7e(i(5 irama nafas5 fre(uensi i. Beri(an 4ron(oilator 4ila 12
'ernafasan alam
'erlu
rentang normal5 tia( aa suara nafas
l. Monitor res'irasi an status >#
a4normal9 7. !ana !ana vital
alam rentang normal Tera$i /%si&en 8te(anan ara5 nai5 a. Bersi(an mulut5 iung an 'ernafasan9 se7ret tra(ea 4. Pertaan(an "alan nafas 0ang 'aten 7. Atur 'eralatan o(sigenasi . Monitor aliran o(sigen e. Pertaan(an 'osisi 'asien f. >4servasi aan0a tana tana i'oventilasi g. Monitor aan0a (e7emasan 'asien teraa' o(sigenasi
ital si&n M#nit#rin&
a. Monitor !D5 nai5 suu5 an RR 4. Catat aan0a flu(tuasi te(anan ara 7. Monitor @% saat (lien 4er4aring5 uu(5 atau 4eriri . Aus(ultasi !D 'aa (eua lengan an 4aning(an e. Monitor !D5 nai5 RR5 se4elum5 selama5 an setela
13
a(tivitas f. Monitor (ualitas ari nai g. Monitor fre(uensi an irama 'erna'asan . Monitor suara 'aru i. Monitor 'ola 'erna'asan a4normal ". Monitor suu5 -arna5 an (elem4a4an (ulit (. Monitor sianosis 'erifer l. Monitor aan0a 7using tria 8te(anan nai 0ang mele4ar5 4rai(ari5 'ening(atan sistoli(9 m. Ientifi(asi 'en0e4a4 ari 'eru4aan vital sign
&
*angguan 'ertu(aran gas N/C 0 4. 'eru4aan mem4ran a. Res'irator0 %tatus = (a'iler3alveolar *as e7ange
NIC 0
Air-a0 Management a. Bu(a "alan nafas5 guana(an
4. Res'irator0 %tatus =
te(ni( 7in lift atau "a- trust
ventilation
4ila 'erlu
7. @ital %ign %tatus
4. Posisi(an 'asien untu( mema(simal(an ventilasi
riteria Hasil 0
a. Menemonstrasi(an
7. Ientifi(asi 'asien 'erlun0a
'ening(atan ventilasi
'emasangan alat "alan nafas
an o(sigenasi 0ang
4uatan
ae(uat
. Pasang ma0o 4ila 'erlu
14
4. Memeliara (e4ersian e. La(u(an fisiotera'i aa "i(a 'aru 'aru an 4e4as
'erlu
ari tana tana istress 'ernafasan
f. Keluar(an se(ret engan 4atu( atau su7tion
7. Menemonstrasi(an 4atu( efe(tif an suara
g. Aus(ultasi suara nafas5 7atat
nafas 0ang 4ersi5 tia( aa sianosis an
aan0a suara tam4aan
. La(u(an su7tion 'aa ma0o
0s'neu 8mam'u mengeluar(an s'utum5 i. Beri(an 4ron(oilator 4ial 'erlu mam'u 4ernafas engan mua5 tia( aa 'urse li's9 . !ana tana vital alam rentang normal
". Bari(an 'elem4a4 uara (. Atur inta(e untu( 7airan mengo'timal(an (eseim4angan. l. Monitor res'irasi an status ># Res'irator0 Monitoring a. Monitor rata rata5 (ealaman5 irama an usaa res'irasi 4. Catat 'ergera(an aa5amati (esimetrisan5 'enggunaan otot tam4aan5 retra(si otot su'ra7lavi7ular an inter7ostal 7. Monitor suara nafas5 se'erti eng(ur . Monitor 'ola nafas = 4rai'ena5 ta(i'enia5 (ussmaul5 i'erventilasi5 7e0ne sto(es5 4iot
15
e. Catat lo(asi tra(ea f. Monitor (elelaan otot iagfragma 8gera(an 'arao(sis9 g. Aus(ultasi suara nafas5 7atat area 'enurunan tia( aan0a ventilasi an suara tam4aan . !entu(an (e4utuan su7tion engan mengaus(ultasi 7ra(les an ron(i 'aa "alan na'as utama i. aus(ultasi suara 'aru setela tina(an untu( mengetaui asiln0a
)
N/C 0
NIC 0
Nutritional %tatus = foo an 2lui Inta(e Risi(o (e(urangan volume 7airan 4eru4ungan engan emam5 menurunn0a riteria Hasil 0 inta(e an ta7i'nea a. Aan0a 'ening(atan 4erat 4aan sesuai engan tu"uan 4. @olume 7airan normal
a. Ka"i aan0a tana eirasi 4. $aga (elan7aran aliran infus 7. Peri(sa aan0a trom4o'le4itis . Pantau tana vital tia' , "am e. La(u(an (om'res ingin "i(a tera'at i'ertermia suu iatas &? C
7. Pengeluaran BAB normal 8tia( ter"ai 'ening(atan9 . !ia( aa tana eirasi e. %uu tu4u normal 16
f. Pantau 4alan7e 7airan g. Beri(an nutrisi sesuai iit . A-asi turgor (ulit
&,5+3& 6C f.
Kelo'a( mata tia( 7e(ung
+
g.
!urgor (ulit 4ai(
.
A(ral angat
Ketia(seim4angan nutrisi N/C 0 NIC 0 (urang ari (e4utuan Nutritional %tatus = foo Nutriti#n Mana&ement tu4u 4. (etia(mam'uan an 2lui Inta(e a. Ka"i aan0a alergi ma(anan 'emasu(an atau men7erna ma(anan atau 4. Kola4orasi engan ali gi;i menga4sor'si ;at3;at gi;i untu( menentu(an "umla riteria Hasil 0 4eru4ungan engan fa(tor (alori an nutrisi 0ang 4iologis5 'si(ologis atau a. Aan0a 'ening(atan 4erat 4aan sesuai i4utu(an 'asien. e(onomi engan tu"uan 7. 4. Berat 4aan ieal
An"ur(an 'asien untu( mening(at(an inta(e 2e
sesuai engan tinggi .
4aan
An"ur(an 'asien untu( mening(at(an 'rotein an
7. Mam'u
vitamin C
mengientifi(asi (e4utuan nutrisi . !ia( aa tana tana
e.
Beri(an su4stansi gula
f.
a(in(an iet 0ang ima(an menganung tinggi serat
malnutrisi
untu( men7ega (onsti'asi e. !ia( ter"ai 'enurunan 4erat 4aan
g.
Beri(an ma(anan 0ang ter'ili 8 sua
0ang 4erarti
i(onsultasi(an engan ali gi;i9 .
A"ar(an 'asien 4agaimana mem4uat 7atatan ma(anan arian.
17
i.
Monitor "umla nutrisi an (anungan (alori
".
Beri(an informasi tentang (e4utuan nutrisi
(.
Ka"i (emam'uan 'asien untu( mena'at(an nutrisi 0ang i4utu(an
Nutriti#n M#nit#rin&
a.
BB 'asien alam 4atas normal
4.
Monitor aan0a 'enurunan 4erat 4aan
7.
Monitor ti'e an "umla a(tivitas 0ang 4iasa ila(u(an
.
Monitor intera(si ana( atau orangtua selama ma(an
e.
Monitor ling(ungan selama ma(an
f.
$a-al(an 'engo4atan an tina(an tia( selama "am ma(an
g.
Monitor (ulit (ering an 'eru4aan 'igmentasi
. i.
Monitor turgor (ulit Monitor (e(eringan5 ram4ut (usam5 an mua 'ata
".
18
Monitor mual an munta
(.
Monitor (aar al4umin5 total 'rotein5 H45 an (aar Ht
l.
Monitor ma(anan (esu(aan
m. Monitor 'ertum4uan an 'er(em4angan n.
Monitor 'u7at5 (emeraan5 an (e(eringan "aringan (on"ungtiva
o.
Monitor (alori an inta(e nuntrisi
'.
Catat aan0a eema5 i'eremi(5 i'ertoni( 'a'ila lia an 7avitas oral.
J. Catat "i(a lia 4er-arna magenta5 s7arlet
NIC 0
2ever treatment a. Monitor suu sesering mung(in 4. Monitor IL ,.
Hi'ertermi
4eru4ungan
engan aan0a 4a(teri an infe(si virus
7. Monitor -arna an suu N/C 0
(ulit
!ermoregulation Kriteria Hasil = a. %uu tu4u alam rentang normal 4. Nai an RR alam 19
. Monitor te(anan ara5 nai an RR e. Monitor 'enurunan ting(at (esaaran f. Monitor BC5 H45 an
H7t g. Monitor inta(e an out'ut . Beri(an anti 'ireti( i.
Beri(an 'engo4atan untu( mengatasi 'en0e4a4 emam
".
%elimuti 'asien
(. La(u(an ta'i s'onge l.
Beri(an 7airan intravena
m. Kom'res 'asien 'aa li'at 'aa an a(sila rentang normal
n. !ing(at(an sir(ulasi uara
7. !ia( aa 'eru4aan -arna (ulit an tia(
(.
o. Beri(an 'engo4atan
aa 'using5 merasa
untu( men7ega
n0aman
ter"ain0a menggigil
Ealuasi
Pasien mam'u= a) Menemonstrasi(an 4atu( efe(tif an suara nafas 0ang 4ersi5 tia( aa sianosis an
0s'neu 8mam'u mengeluar(an s'utum5 mam'u 4ernafas engan mua5 tia( aa 'urse li's9. b)
Menun"u((an "alan nafas 0ang 'aten 8(lien tia( merasa ter7e(i(5 irama nafas5 fre(uensi 'ernafasan alam rentang normal5 tia( aa suara nafas a4normal9.
c)
Mam'u mengientifi(asi(an an men7ega fa7tor 0ang a'at mengam4at "alan nafas.
d)
!ana3tana vital alam rentang normal 8te(anan ara5 nai5 'ernafasan9. 20
e)
Memeliara (e4ersian 'aru 'aru an 4e4as ari tana tana istress 'ernafasan.
)
Pasien menun"u((an tia( aan0a tana3tana emam5 suu alam 4atas normal.
g)
Pasien an (eluarga men0ata(an 'emaaman tentang 'en0a(it5 (onisi5 'rognosis an 'rogram 'engo4atan.
!)
Pasien an (eluarga mam'u mela(sana(an 'roseur 0ang i"elas(an se7ara 4enar.
i)
Pasien an (eluarga mam'u men"elas(an (em4ali a'a 0ang i"elas(an 'era-attim (eseatan lainn0a.
BAB III PENUTUP A. esim$ulan Bron7o'neumonia aala infe(si 0ang men0e4a4(an 'aru3'aru meraang. Kantung3 (antung uara alam 'aru 0ang ise4ut alveoli i'enui nana an 7airan seingga (emam'uan men0era' o(sigen men"ai (urang. Ke(urangan o(sigen mem4uat sel3sel tu4u tia( 4isa 4e(er"a. Karena itu5 selain 'en0e4aran infe(si (e seluru tu4u5 21
'enerita
4ron7o'neumonia 4isa
meninggal.
%e4enarn0a
4ron7o'neumonia
4u(anla 'en0a(it tunggal. Pen0e4a4n0a 4isa 4erma7am3ma7am an i(etaui aa &6 sum4er infe(si5 engan sum4er utama 4a(teri5 virus5 mi(ro'lasma5 "amur5 4er4agai sen0a-a (imia mau'un 'arti(el.
B. "aran Dari (esim'ulan iatas 'enulis a'at sei(it mem4eri saran (e'aa 4e4era'a 'ia( untu( mem'er4ai(i an mening(at(an (ualitas 'ela0anan (eseatan utaman0a i Inonesia5 iantaran0a se4agai 4eri(ut= 1. Keluarga (lien atau 'asien Keluarga (lien atau 'asien iara'(an a'at mem4eri(an 'era-atan alam memenui
(e4utuan
seari3ari
ana(n0a
0ang
menerita
'en0a(it
4ron(o'neumonia an mam'u men"aga (e4ersian ling(ungan seingga setia' anggota (eluarga 0ang lain a'at terinar ari 'en0a(it 4ron(o'neumonia. #. Maasis-a Maasis-a iara'(an mam'u menguasai (onse' 4ro(o'neumonia utaman0a alam mem4eri(an asuan (e'era-atan engan intensif 'aa ana( engan 4ron(o'neumonia an mem4eri(an 'en0uluan 'aa (eluarga 'asien se4agai usaa untu( mem'er7e'at 'en0em4uan 'asien serta men7ega ter"ain0a (om'li(asi. Maasis-a a'at men"alin (er"a sama engan (eluarga5 'era-at lainn0a5 agar a'at mela(sana(an asuan (e'era-atan se7ara o'erasional.
DATAR PU"TAA Alimul5 A A;i;. #66/. Pengantar Ilmu Kesehatan Anak untuk Pendidikan Kebidanan . $a(arta = %alem4a Mei(a Brunner < %urat. #66#. Keperawatan Medikel Bedah. E*C= "a(arta. De'artemen Keseatan RI 81//,9. Pusat Penyuluhan Kesehatan Masyarakat 5 De'(es $a(arta. Martin tu7(er5 %usan. #666. Standar Perawatan Pasien: Proses Keperawatan, Diagnosis, 22
Dan!aluasi halaman "#$.E*C= $a(arta. Mans"oer5 Arif.#666. Kapita Selekta Kedokteran. disi ke % &ilid ke ". Media Aes'ulapius.2a(ultas Keo(teran Universitas Inonesia=$a(arta. Nurarif5 Amin Hua5 ((. #61+. Aplikasi Asuhan Keperawtan Berdasarkan Diagnosa Medis dan (anda (i' (o' &ilid ). $og"a(arta = Per7eta(an Meia7tion $og"a Nursalam. #66+. Asuhan Keperawatan Bayi dan Anak . $a(arta= %alem4a Mei(a %0lvia A. Pri7e < Lorraine M.. #66,. Pato*isiologi konsep klinis dan proses+proses penyakit. E*C= $a(arta. %anra M Nettina.#661. ippin'ott -Manual Praktik Keperawatan. $a(arta = E*C. %oe'arman5 ((. #661. Ilmu Pen0a(it Dalam $ili II. $a(arta = Balai Pener4it 2KUI il(inson5 $uit M. #611. Buku Saku Diagnosis Keperawatan: diagnosis NANDA, intervensi NIC, kriteria hasil NOC, ed 9 $a(arta= E*C
23