I.01009 Manajemen Asam Basa Asidosis Respiratorik
Definisi : Mengidentifikasi dan mengelola kondisi darah asam akibat tingginya tekanan parsial karbon dioksida
Tindakan
Observasi
- Identifikasi penyebab asidosis respiratorik (mis. PPOK, asma, cedera kepala, edema paru, pneumonia, ARDS, pneumothoraks, henti jantung, obstruksi jalan napas, depresi pernapasan, depresi SSP, trauma dada, gagal jantung) – Monitor adanya hipoventilasi
- Monitor frekuensi dan kedalaman napas
- Monitor penggunaan otot bantu napas
- Monitor CTR (Capillary refill time)
- Monitor adanya indikasi asidosis respiratorik kronik (mis. barrel chest, penggunaan otot bantu napas, clubbing nails)
- Monitor dampak susunan saraf pusat (mis. penurunan kesadaran, konfusi)
- Monitor hasil analisa gas darah
- Monitor adanya komunikasi
Terapeutik
- Pertahankan kepatenan dan bersihan jalan napas
- Berikan oksigenasi aliran rendah pada kondisi hiperkapnia kronik (PPOK)
- Pertahankan akses intra vena
- Berikan oksigen, sesuai indikasi
- Hindari koreksi hiperkapnia dalam waktu tertentu terlalu cepat karena dapat menyebabkan alkalosis metabolik
Edukasi
- Jelaskan penyebab dan mekanisme terjadinya asidosis respiratorik
- Anjurkan berhenti merokok
- Anjurkan menurunkan berat badan, Jika obesitas
- Ajarkan latihan pernapasan
Kolaborasi
- Kolaborasi pemberian ventilasi mekanik, Jika perlu
- Kolaborasi pemberian bronkodilator, Jika perlu
- Kolaborasi pemberian antidotum opiate (naloxone), Jika perlu
Daftar Pustaka
PPNI (2018). Standar Intervensi Keperawatan Indonesia.
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