I.01019 Pengaturan Posisi

Definisi : Menempatkan bagian tubuh untuk meningkatkan kesehatan fisiologis dan atau psikologis

Tindakan

Observasi

  1. Monitor status oksigen sebelum dan sesudah mengubah posisi
  2. Monitor alat traksi agar selalu tepat

Terapeutik

  1. Tempatkan pada matras atau tempat tidur terapiutik yang tepat
  2. Tempatkan pada posisi terapeutik
  3. Tempatkan objek yang sering digunakan dalam jangkauan
  4. Tempatkan bel atau lampu panggilan dalam jangkauan
  5. Sediakan matras yang kokoh atau padat
  6. Atur posisi tidur yang disukai, jika tidak kontraindikasi
  7. Atur posisi untuk mengurangi sesak (mis. semi Fowler)
  8. Atur posisi yang menghilangkan drainage
  9. Posisikan pada kesejajaran tubuh yang tepat
  10. Imobilisasi dan topeng bagian tubuh yang cedera dengan tepat
  11. Tinggikan bagian tubuh yang sakit dengan tepat
  12. Tinggikan anggota gerak 20° atau lebih di atas level jantung
  13. Tinggikan tempat tidur bagian kepala
  14. Berikan bantal yang tepat pada leher
  15. Berikan topangan pada area edema (mis. bantah dibawah lengan dan skrotum)
  16. Posisikan untuk mempermudah ventilasi atau perfusi (mis. tengkurap/good lung down)
  17. Motivasi melakukan ROM aktif atau pasif
  18. Motivasi terlibat dalam perubahan posisi, sesuai kebutuhan
  19. Hindari menempatkan pada posisi yang dapat meningkatkan nyeri
  20. Hindari menempatkan stump amputasi pada posisi fleksi
  21. Hindari posisi yang menimbulkan ketegangan pada luka
  22. Minimalkan gesekan dan tarikan saat mengubah posisi
  23. Ubah posisi setiap 2 jam
  24. Ubah posisi dengan teknik log roil
  25. Pertahankan posisi dan integritas traksi
  26. Jadwalkan secara tertulis untuk perubahan posisi

Edukasi

  1. Informasikan saat akan dilakukan perubahan posisi
  2. Ajarkan cara menggunakan poster yang baik dan mekanika tubuh yang baik selama melakukan perubahan posisi

Kolaborasi

  1. Kolaborasi pemberian premedikasi sebelum mengubah posisi, jika perlu

Daftar Pustaka

PPNI (2018). Standar Intervensi Keperawatan Indonesia.

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