Asuhan Keperawatan Acute Respiratory Failure Et Causa Pneumonia di Intensive Care Unit: Studi Kasus
DOI:
https://doi.org/10.32583/jgd.v6i1.2144Keywords:
acute respiratory failure, asuhan keperawatan, pneumoniaAbstract
Komplikasi yang dapat terjadi pada pneumonia adalah acute respiraty failure. Acute respiratory failure pada pneumonia dapat terjadi karena peradangan akut pada saluran udara sehingga mengakibatkan gagal napas dengan angka mortalitas mencapai 90%. Hasil pengkajian didaptkan Ny. A usia 34 tahun dengan keluhan batuk, sesak napas, lemas, tidak dapat menelan, nyeri ulu hati, demam, sariawan, hematuria, penurunan kesadaran, serta mengalami IUFD. Studi kasus ini bertujuan untuk menyampaikan asuhan keperawatan pada pasien Acute Respiratory Failure et causa Pneumonia di Intensive Care Unit Rumah Sakit Umum Daerah dr. Zainoel Abidin Banda Aceh. Metode yang digunakan adalah kuantitatif deskriptif dengan pendekatan studi kasus. Penelitian ini dilakukan selama tiga hari pada tanggal 04 – 06 Mei 2023 dengan pendekatan asuhan keperawatan yang terdiri dari pengkajian, penentuan diagnosa keperawatan, intervensi, implementasi, dan evaluasi yang mengacu pada SDKI, SIKI, SLKI. Diagnosis keperawatan pada kasus ini adalah gangguan pertukaran gas, gangguan penyapihan ventilator, risiko syok, risiko infeksi, risiko aspirasi, hipervolemia, dan risiko perdarahan. Intervensi keperawatan yang diberikan adalah pemantuan respirasi, manajemen ventilasi mekanik, penyapihan ventilasi mekanik, pencegahan syok, pencegahan infeksi, pencegahan aspirasi, manajemen hypervolemia, pemantauan cairan, dan pencegahan perdarahan. Hasil evaluasi belum terdapat perbaikan pada kondisi pasien, ditandai dengan Tekanan Darah: 82/51 mmHg, Mean Arterial Pressure (MAP): 61 mmHg, frekuensi nadi: 155x/menit, SpO2: 92%, pH 7.325 mmHg, PCO2 79.8 mmHg, PO2 67 mmHg, HCO3 41.5 mmol/L, pasien terpasang ventilator mode PCV+ dan terdapat edema perifer.
References
Abdjul, R. L., & Herlina, S. (2020). Asuhan Keperawatan Pada Pasien Dewasa dengan Pneumonia: Study Kasus. Indonesian Jurnal of Health Development, 2(2), 102–107.
Bellani G, L. J. (2022). Epidemiology, Patterns of Care, and Mortality for Patients With Acute Respiratory Distress Syndrome in Intensive Care Units in 50 Countries. JAMA, 788-800
Beverly, A., Walter, E., & Carraretto, M. (2016). Management of endotracheal tube. Journal of the Intensive Care Society, 17(1), 88–89. https://doi.org/10.1177/1751143715601124
Cable, C. A., Razavi, S. A., Roback, J. D., & Murphy, D. J. (2019). Management of hypervolemic patients. Critical Care Medicine, 47(11), 1637–1644. https://doi.org/10.1097/CCM.0000000000003985
Cannon, J., Pamplin, J., Zonies, D., Mason, P., Sine, C., Cancio, L., McNeill, J., Colombo, C., Osborn, E., Ricca, R., Allan, P., DellaVolpe, J., Chung, K., & Stockinger, Z. (2018). Acute respiratory failure. Military Medicine, 183, 123–129. https://doi.org/10.1093/milmed/usy151
Cecconi, M., Evans, L., Levy, M., & Rhodes, A. (2018). Sepsis and septic shock. The Lancet, 392(10141), 75–87. https://doi.org/10.1016/S0140-6736(18)30696-2
Chang, J. C. (2022). Acute Respiratory Distress Syndrome as an Organ Phenotype of Vascular Microthrombotic Disease: Based on Hemostatic Theory and Endothelial Molecular Pathogenesis. Clinical and Applied Thrombosis/Hemostasis, 25. https://doi.org/10.1177/1076029619887437
Chen, J., Chang, C., Huang, Y., & Kuo, G. (2020). Reto De Furosemide. 1–13.
Chen, J., Liu, R., Wu, X., Zhu, Z., He, R., Yang, F., & Deng, S. (2021). Application of Nursing Risk Management in Nursing of Severe Acute Respiratory. Yangtze Medicine, 05(03), 226–234. https://doi.org/10.4236/ym.2021.53021
Doenges, M. E., & Moorhouse, F. M. (2018). Management respiratory rate. F.A Davis Company.
Haghighat, S., & Yazdannik, A. R. (2019). Performing oral hygiene on ICU patient. Iranian Journal of Nursing and Midwifery Research, 20(5), 619–625. https://doi.org/10.4103/1735-9066.164509
Higgs, A., McGrath, B.A., Goddard, C., Rangasami, J., Suntharalingam, G., Gale, R., & Cook, T.M. (2019). Guidelines for the management of tracheal intubation in critically ill adults. British Journal of Anaesthesia. doi: 10.1016/j.bja.2017.10.021
Kakihana, Y., Ito, T., Nakahara, M., Yamaguchi, K., & Yasuda, T. (2018). Complications that occur in IUFD. Journal of Intensive Care, 4(1), 1–10. https://doi.org/10.1186/s40560-016-0148-1
Kementerian Kesehatan Republik Indonesia. (2022). Riset Kesehatan Dasar.
Khasanah, M. (2019). Asuhan keperawatan pada pneumonia di ruang kanthil rumah sakit umum daerah banyumas. Jurnal Penelitian Kesehatan, 11(1), 9-40. https://doi.org/10.33846/sf11116
Lee, E.S,H., lim, D.T.J., Taculod, J.M., Juliet, T.S., Otero, J.P., Teo, K.,…& Tan, A.Y.H. (2017). Factors associated with reintubation in an intensive care unit: A prospecive observational study. Indian Journal of Critical Care Medicine 21(3), 131-137
Lusaya, D. G. (2022). Nursing care for endotracheal tube patient. Medscape. https://emedicine.medscape.com/article/436259-overview
Mandan, A. N. (2019). Asuhan Keperawatan Pada Pasien Dewasa Penderita Pneumonia Dengan Ketidakefektifan Bersihan Jalan Napas.
Miu, T., Joffe, A. M., Yanez N.D., Khandelwal, M.D., Dagal, A.H.C., Deem, S., Treggiari, M.M., (2017). Predictors of Reintubation in Critically ill patients. Respiratory care, 59 (2), 178-185.
Palmer, B. F., & Clegg, D. J. (2020). Fluid overload as a therapeutic target for the preservative management of Pneumonia. Current Opinion in Nephrology and Hypertension, 29(1), 22–28. https://doi.org/10.1097/MNH.0000000000000563.
PPNI. (2017). Standar Diagnosis Keperawatan Indonesia: Definisi dan Indikator Diagnostik, Edisi 1. Jakarta: DPP PPNI.
PPNI. (2018a). Standar Intervensi Keperawatan Indonesia: Definisi dan Tindakan Keperawatan, Edisi 1. Jakarta: DPP PPNI.
PPNI. (2018b). Standar Luaran Keperawatan Indonesia: Definisi dan Kriteria Hasil Keperawatan, Edisi 1. Jakarta: DPP PPNI.
Riley, L. K., & Rupert, J. (2016). Penumonia therapy. American Family Physician, 92(11), 1004–1011.
Rello, J., Valenzuela-Sánchez, F., Ruiz-Rodriguez, M., & Moyano, S. (2017). Sepsis: A Review of Advances in Management. Advances in Therapy, 34(11), 2393–2411. https://doi.org/10.1007/s12325-017-0622-8
Setia, S., Alwi, I., Sudoyo, A. W., Simadibrata, M., Setiyahadi, B., & Ari Fahrial Syam. (2019). Buku Ajar Ilmu Penyakit Dalam (VI). Interna Publishing.
Silva, L.C.R., Tonelis, L.S., oliveira, R..C.C., Lemos, P.L., Matos, S.S., & Chianc, T.C.M. (2020). Clinical study of dysfunctional ventilaory weaning response in critically ill patients. Revista Latino-Americana de Enfermagem, 28, 1-13. doi:10.1590/1518-8345.3522.3334
Singer, M., Deutschman, C. S., Seymour, C. W., Shankar-Hari, M., Annane, D., Bauer, M., Bellomo, R., Bernard, G. R., Chiche, J.-D., Coopersmith, C. M., Hotchkiss, R. S., Levy, M. M., Marshall, J. C., Martin, G. S., Opal, S. M., Rubenfeld, G. D., Poll, T. van der, Vincent, J.-L., & Angus, D. C. (2016). Management of pneumonia. The Journal of the American Medical Assosiation, 315(8), 801–810. https://doi.org/doi:10.1001/jama.2016.0287
Souza, P.C., Jeronimo, I.R.l., Vianna, C.A., Benevides, A.B., Santan, R.F., & Brandao, M.A.G. (2020). Spontaneous breathing test as a predivtor of the dysfunctional ventilatory weaning response in intersive care. Revista De Enfermagemda UFSM, 10 (67), 1-17. doi: 10.5902/217976924227
Stancu, S., Mircescu, G., Mocanu, A., Capusa, C., & Stefan, G. (2018). Respiratory Acidosis of Pneumonia and Cardiovascular Disorders. Maedica, 13(4), 267–272. https://doi.org/10.26574/maedica.2018.13.4.267
Suprayogi, E., Sudarsono, & Harijanto, E. (2018). Penyakit Gangguan Pernapasan. Journal Anesthesia & Critical Care, 36(1), 9–18. https://journal.perdatin.org/index.php/macc/article/download/105/68
Thille, A. W., Ehrmann, S., Lascarrou, J. B., & Aissaoui, N. (2018). The impact that occurs on unconscious patient in the ICU. Annals of Intensive Care, 8(1). https://doi.org/10.1186/s13613-018-0424-4
Wang, L., Wang, M., Du, J., & Gong, Z. cheng. (2017). Pneumonia patient with respiratory acidosis. Heliyon, 9(3), e14063. https://doi.org/10.1016/j.heliyon.2023.e14063
Wason, S. E., Monfared, S., Ionson, A., Klett, D. E., & Leslie, S. W. (2023).The incedence rate of aspiration in intensive care unit patent. https://www.ncbi.nlm.nih.gov/books/NBK5 60556/#_article-23688_s14_
World Health Organization. (2021). Pneumonia. https://www.who.int/news-room/fact-sheets/detail/sepsis
Zein, H., Baratloo, A., Negida, A., & Safari, S. (2018). Ventilator weaning and spontaneous breathing educational review. Emergency, 4 (2), 65-71
