Manajemen Demam l.03099 Hal-161
Definisi
Mengidentifikasi dan mengelola peningkatan subu tubuh akibat
pirogen endogen.
Tindakan
Observasi
- Monitor
tanda-tanda vital (mis. suhu tubuh, frekuensi nadi, frekuensi napas dan tekanan
darah )
- Monitor
intake dan output cairan
- Monitor
komplikasi akibat demam (mis. kejang, penurunan kesadaran, kadar elektrolit
abnormal, ketidakseimbangan asam-basa,aritmia)
Teraupetik
- Tutupi
badan dengan selimut/pakaian dengan tepat (mis. selimut/pakaian tebal saat
merasa dingin dan selimut/ pakaian tipis saat merasa panas)
- Lakukan
tepid sponge, jika perlu
- Berikan
oksigen, jika perlu
Edukasi
-
Anjurkan tirah baring
-
Anjurkan memperbanyak minum
Kolaborasi
-
Kolaborasi pemberian cairan dan elektrolit intravena, jika perlu
-
Kolaborasi pemberian antipiretik, jika perlu
-
Kolaborasi pemberian antibiotik, jika perlu
Referensi
Berman, A., Snyder, S. & Fradsen, G. (2016). Kozier &
Erb's Fundamentals of Nursing (10th ed.). USA
Dougherty, L. & Lister, S. (2015). Manual of Clinical Nursing
Procedures (9th ed.). UK: The Royal Marsden
NHS Foundation Trust.
Grainger, A. (2013). Principles of temperature monitoring. Nursing
Standard, 27(50), 48-55. Hunt, J. (2007). Fever management. Paediatric Nursing,
19(4), 10.
Perry, A.G. & Potter, P. A. (2014). Nursing Skills &
Procedures (8th ed.). St Louis: Elsevier
Wang, Y., & Huang, M. (2008). Using evidence-based nursing to
explore the management of child fever. Hu U Ze Zhi The Journal Of Nursing,
55(2), 10-15.
Wilkinson, J. M., Treas, L. S., Bamett, K. & Smith, M. H.
(2016). Fundamentals of Nursing (3rd ed.). Philadelphia: F. A. Davis Company.
Yong Soon, S., Sung Reul, K., Sung-Hes, Y., Sun Hwa, K., Jeoung
Hee, K., Hyun Jung, K., &... Kyoung-Ok, K. (2013). Development and
Evaluation of an Evidence-Based Nursing Protocol for Fever Management in Adult
Patients. Korean Journal of Adult Nursing, 25(3), 250-262. doi:
10.7475/kjan.2013.25.3.250.
Pearson Education.
