Nursing in Patient With Food Allergies

7/25/2019 Nursing in Patient With Food Allergies

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NURSING IN PATIENT WITH FOOD ALLERGIES

A. BASIC CONCEPTS OF DISEASE

1. Definition / Definitions

Food allergy is the body's abnormal response to a food triggered by a specific reaction

in the immune system with specific symptoms as well

Food allergy is a collection of symptoms that affect many organs and body systems

caused by allergies to foods.

In some food allergy literature used to express a reaction to a food that is essentially a

type I hypersensitivity reactions and hypersensitivity to food is a hypersensitivity

reaction type III and IV.

2. Epie!io"o#$Food allergies can affect anyone with a level that is different. By the time a

person ate food then raised an uneasy feeling in his body then they will assume that

they are allergic to these foods. Facts prove, not all of these assumptions is true. Only

! of adults and "! in children who proved if they are truly allergic to certain foods.

Food allergies usually occur in children. #pproximately $%! of infants allergic

to cow's mil&, about ! of children showed adverse reactions to food, and %! of

adults also suffer from allergies incidence of food allergy between Ig( and a type I

hypersensitivity ranged from ).! to *.)! of the population.

%. Etio"o#$

Factors that play a role in our food allergies divided into two, namely+

&. Inte'n&" F&(to's

Intestinal immaturity functionally eg in functions+ stomach acid, an en-yme$

intestinal en-ymes, glycocalyx and immunological functions eg, secretory

Ig# facilitate the penetration of food allergens. Immaturity also reduce the

ability of the intestine to tolerate certain foods.

/enetic role in food allergies. #llergen sensiti-ation early start to the fetus

through infancy and sensiti-ation is influenced by the local customs and norms

of life.

0u&osa 1all immature digestive tract that causes increased absorption of

allergens.

). f&*o' E+te'n&"

2recipitating factors+ physical factors cold, heat, rain, psychological factors

sadness, stress or load exercise running, sports.

(xamples of foods that can provide according to the prevalence of allergic

reactions.


2/23

Fish 3.4!

(ggs %.*!

0il& %.%!5uts 3."!

1heat 4.*!

#pples 4.*!

2otato %.6!

Brown %.!2igs .3!

7ows ".!

#lmost all &inds of food and additives in foods can cause allergic reactions.

,. P&t-op-$sio"o#$

8he first time inclusion of allergens ex. (gg into the body of a person who

consumes food but he had never been exposed to allergies. 9owever, when for thesecond time the person consuming the same food then loo&s symptoms $ symptoms of

the onset of allergic s&in tersebut. #fter sign $ a sign that appeared the antigen will

recogni-e incoming allergens that would trigger active 8 cells, where the 8 cells that

would stimulate B cells to activate antibodies Ig(. 8his process resulted in antibodies

attach to mast cells released by basophils. If someone is having a second time by

exposure to the same allergen, there will be two things+

a. 1hen the start of the cyto&ine production by 8 cells cyto&ines have an effect on

various cells, especially in attracting cells $ inflammatory cells eg neutrophils and

eosinophils, causing an inflammatory reaction which causes heat.

b. #llergens will immediately activate antibodies Ig(, which stimulates mast cellsthen release histamine in significant amounts, then the circulating histamine in the

body through the blood vessels. 1hen they reach the s&in, allergens will cause

itching, prutitus, angioderma, urticaria, redness of the s&in and dermatitis. By the

time they reach the lungs, allergens can trigger asthma. 8he most feared symptoms

of allergy &nown as anaphylactic shoc&. 8his phenomenon is mar&ed by decreased

blood pressure, decreased consciousness, and if not treated immediately can cause

death

. C"&ssifi(&tion

&. An&fi"&*tif -$pe'sensitiit$ 0t$pe 1

8his situation is an immediate hypersensitivity reaction anafila&tif that began

within a few minutes after contact with antigen.

). C$toto+i( -$pe'sensitiit$ 0t$pe 2

7ytotoxic hypersensitivity of the immune system mista&enly recogni-es normal

constituents of the body as a foreign ob:ect.

(. I!!ne (o!p"e+ -$pe'sensitiit$ 0t$pe %

Immune complexes formed when antigen is bound to antibody and cleared from

the blood circulation through phagocytic wor&.

. S"o3 t$pe -$pe'sensitiit$ 0t$pe ,


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8his reaction is also &nown as cellular hypersensitivity, occurs %4 to *% hours after

contact with an allergen.

4. C"ini(&" S$!pto!s

8he clinical symptoms+

In the respiratory tract+ asthma.

In the gastrointestinal tract+ nausea, vomiting, diarrhea, abdominal pain.

On the s&in+ urticaria. angioderma, dermatitis, pruritus, itching, fever, itching.

In the mouth+ the itching and swelling of lips.

5. P-$si(&"

Inspection+ if there is redness, bumps, and there are symptoms of urticaria,

angioderma, pruritus and swelling of the lips.

2alpation+ no tenderness redness.

2ercussion+ find out whether there is air or fluid in the belly.

#uscultation+ listening to breath sounds, heart sounds, bowel sounds.

6. Sppo'tin#

S*in test7as a survey filter eg by inhaled allergens such as dust mites, &apo&,

house dust, cat dander, grass pollen, or food allergens such as mil&, eggs, nuts,fish.

Pe'ip-e'&" )"oo7eosinophilia when 3! or 3)) ; ml inclined to allergies. 8he

leu&ocyte count of 3))) ; ml with "! neutropenia often found in food allergies.

Tot&" &n spe(ifi( I#E7total Ig( normal price is )))u ; l up to the age of %)

years. Ig( levels over ")u ; ml generally indicates that the patient is atopy, or

parasitic infections or cellular immune depression.

Intradermal test value is limited, dangerous.

9emagglutinin and antibody tests are not sensitive precipitates.

Intestinal biopsy+ secondary and stimulated with food after food chalenge obtained

inflammatory ; atrophy of the intestinal mucosa, increased intraepithelial

lymphocytes and Ig0. Ig( with immunofluorescent microscopy.

Inspection ; test < =ylose, pro&tosigmoidos&opi and intestinal biopsy.


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/astrointestinal disorders with diarrhea or nausea and vomiting, for example+

pyloric stenosis, 9irschsprung, en-yme deficiency, galactosemia, a malignancy

with obstruction, cystic fibrosis, peptic disease and so on.

>eaction due to contaminants and additive materials, eg dyes and preservatives,

sodium metabisulfite, monosodium glutamate, nitrites, tartra-ine, toxins, fungi

aflatoxin, fish related scombroid, ciguatera, bacteria ?almonella, (scherichiacoli, ?higella , viruses rotavirus, enterovirus, parasites /iardia, #&is simplex,

heavy metals, pesticides, caffeine, glycosidal al&aloid solanine, histamine the

fish, serotonin banana, tomato, triptamin tomato, tyramine cheese etc.

>eaction psychology.

19. T-e'&p$ / T'e&t!ent

8here are several dietary regimens that can be used+

"Elimination DIET":some foods should be avoided, namely fruits, mil&, eggs,

fish and beans, in ?urabaya is famous for stands B?8I@. #re foods that are found

to cause allergic symptoms, so foods with a high index of allergenicity. 8his index

may be another for the other regions, for example by


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Ased primarily in patients with symptoms of asthma and allergic rhinitis.

C'o!o"$ngenerally effective on food allergies with symptoms of atopy dermatitis

caused by food allergies.


6/23

Food allergies often improves in a certain age. #fter % years of age are usually

immaturity of the gastrointestinal tract will improve. ?o that after the age of

gastrointestinal disorders due to food allergies will also be reduced. 1hen

gastrointestinal disorders will improve the disorder usually ter:adipun behavior will be

reduced. Furthermore, at the age of 3 or * years allergy 0eals are to be reduced

gradually. Food allergy symptom improvement with age is what illustrates that#utismepun symptoms will usually appear improved since the age period. #lthough

specific food allergies usually will persist into adulthood, such as shrimp, crab or

peanuts.

B. NURSING

I. PENG;A


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2atients complain of abdominal pain, shortness of breath, fever, swollen lips,

tibul redness of the s&in, nausea, vomiting, and itchy intolerable that the patient

was ta&en to hospital.

2ast 0edical 9istory

#ssess whether the patient previously had experienced the same pain or

associated with a disease that currently afflicts. For example, earlier said thepatient had experienced abdominal pain, shortness of breath, fever, swollen

lips, tibul redness of the s&in, nausea, vomiting, and itchy and had been

undergoing treatment in hospitals or certain medications.

Family 9ealth 9istory

#ssess whether the patient's family there is ; are not experiencing the same

disease.

2sychosocial and ?piritual 9istory

>eviewing those closest to the patient, the interaction within the family, the

impact of the patient's illness on the family, the problem affects patients coping

mechanism to stress, the patient's perception of the disease, the tas& of

development according to current age, and the value system of trust.

%. Assesse )$ 1, )&si( nees &((o'in# to >i'#ini& H&ne'son: n&!e"$7

&. Breathe

#ssess whether the patient has respiratory problems, tightness, or cough, as

well as measuring respiration rate.

). (at

#ssess whether the client spent eating the provided >?, if patients experience

nausea or vomiting or both.

(. ?8+ a

contributing factor, the Duality ; Duantity, location, duration and scale of pain#. 2ersonal hygiene

7leanliness studied patients while hospitali-ed

-. ?ense of security

#ssess whether patients feel anxious every nursing actions were given to him,

and whether the patient feel more secure when accompanied by his family while

in the hospital.

i. ?ocial and communication

(xamined how the interaction patient to family, hospital personnel and the

environment including to other patients.

=. @nowledge

#ssessed the level of patients' &nowledge about the disease that affects currentand therapies that will be given to recovery.


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*. >ecreation

#ssess whether the patient has a hobby or other activities that he en:oys.

". ?piritual

?tudied how perceptions of patients about the disease, whether patients received

disease is due purely by medical illness or vice versa.

,. P-$si(&" e+&!in&tion

&. /eneral state

? 8he level of awareness of 77?.

). Vital signs

(. 2hysical state

o 9ead and nec&

o 7hest

o Breast and armpit

o #bdomen

o /enitalia

o Integument

o (xtremity

o 5eurologic examination

. E+&!in&tion Sppo't

&. s*in test7as a survey filter eg by inhaled allergens such as dust mites, &apo&,

house dust, cat dander, grass pollen, or food allergens such as mil&, eggs, nuts,

fish.

). B"oo e#e7if eosinophilia 3! or 3)) ; ml inclined to allergies. 8he leu&ocyte

count of 3))) ; ml with "! neutropenia often found in food allergies.

(. Tot&" &n spe(ifi( I#E7total Ig( normal price is )))u ; l up to the age of %)

years. Ig( levels over ")u ; ml generally indicates that the patient is atopy, or

parasitic infections or cellular immune depression.

. intradermal test value is limited, dangerous.

e. 8est hemagglutinin and antibody precipitates insensitive.

f. Intestinal biopsy+ secondary and stimulated with food after food chalenge

obtained inflammatory ; atrophy of the intestinal mucosa, increased intraepithelial

lymphocytes and Ig0. Ig( with immunofluorescent microscopy.

#. (xamination ; test < =ylose, pro&tosigmoidos&opi and intestinal biopsy.


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o 5auseous vomit

o /rimacing, restlessness

o 8here is pain in the abdomen

o Itchy rash

o 7ough

). Ob:ective data

8he use of O%

>edness of the s&in

Coo& pale

?welling of the lips

Fever body temperature above "*.3 )7.

II. NURSING DIAGNOSES

1. T-e n'sin# inosis 3e (&n t&*e7

&. Ineffe(tie )'e&t-in# p&tte'n 'e"&te to e+pos'e to &""e'#en.

). Hipe'te'!i &sso(i&te 3it- inf"&!!&to'$ p'o(esses.

III. RENCANA NURSING

1. Ineffe(tie )'e&t-in# p&tte'n 'e"&te to e+pos'e to &""e'#en

O)=e(ties7after being given as&ep for ... .x3 minutes. patients are expected toshow an effective breathing pattern with the freDuency and depth of the normal

range.

E+pe(te ot(o!es7

8he patient's normal breathing freDuency 6$%) times per minute

8he patient does not feel claustrophobic again

2atients do not seem to wear breathing apparatus

8here are no signs of cyanosis


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Intervention +

&. #ssess the freDuency, depth of breathing and lung expansion. >ecord the

respiratory effort, including muscle pengguanaan aids ; widening mass.

> ;+ speed usually increases. ;+ decreased breath sounds ; no if airway obstruction secondary to bleeding,

clots ; small airway collapse atelectasis. >onci and whee-ing accompanies

obstruction of the airway ; respiratory failure.

(. (levate the head and help change the position. 1a&e the patient gets out of bed

and ambulansi as soon as possible.

> ;+ sitting height enables lung expansion and ease breathing. 7hanging the

position and ambulansi increase air charging different segments of the lung, thusimproving gas diffusion.

. Observations pattern of coughing and secret character.

> ;+ alveolar congestion resulting in a dry cough or irritation. Bloody sputum

can be caused by excessive tissue damage or anticoagulants.

e. /ive supplemental oxygen

> ;+ maximi-e breathing and lower the breath wor&.

f. 2rovide additional humidification, eg ultrasonic nebuli-er.

#. > ;+ provide moisture to the mucous membranes and helps dilution secret for

easy cleaning.

2. Hipe'te'!i &sso(i&te 3it- inf"&!!&to'$ p'o(esses

O)=e(ties7after being given as&ep ... .x.%4 hour expected during the patient's

body temperature decreases

E+pe(te ot(o!es7

8he patient bac& to normal body temperature "6.3 @C$"*.3 @C

2atients no longer swollen lips

Inte'ention7

&. 0onitor the patient's temperature the degree and pattern

> ;+ 8emperature ",$4,7 showed an acute infectious disease process.

). 0onitor the temperature of the environment, limit or add bed linen as indicated

> ;+ >oom temperature ; blan&ets should be changed to maintain near normal.

(. /ive compress warm bathG avoid the use of alcohol

> ;+ 7an help reduce fever


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BIBLIOGRAPH

Brunner H ?uddarth. %))%. Textbook of Medical Surgical Nursing, volume 3,a&arta+ (/7 ..

7arpenito C


12/23

2rice H 1ilson.%))".at$op$%siolog% !linical rocesses concept en%akit#&ol '.(disi

6.a&arta+ (/7.

ASUHAN ;EPERAWATAN PADA PASIEN DENGAN

ALERGI A;ANAN

A. ;ONSEP DASAR PENA;IT

1. Pen#e'ti&n/Definisi


13/23

#lergi ma&anan adalah respon abnormal tubuh terhadap suatu ma&anan yang

dicetus&an oleh rea&si spesifi& pada sistem imun dengan ge:ala yang spesifi& pula

#lergi ma&anan adalah &umpulan ge:ala yang mengenai banya& organ dan sistem

tubuh yang ditimbul&an oleh alergi terhadap bahan ma&anan.


14/23

7ontoh ma&anan yang dapat memberi&an rea&si alergi menurut prevalensinya

I&an 3,4 !

8elur %,* !

?usu %,% !

@acang 3," !

/andum 4,* !

#pel 4,* !

@entang %,6 !

7o&lat %, !

Babi ,3 !

?api ", !

9ampir semua :enis ma&anan dan -at tambahan pada ma&anan dapat

menimbul&an rea&si alergi.

,. P&tofisio"o#i

?aat pertama &ali masu&nya alergen ex. telur &e dalam tubuh seseorang yangmeng&onsumsi ma&anan tetapi dia belum pernah ter&ena alergi. 5amun &eti&a untu&

&edua &alinya orang tersebut meng&onsumsi ma&anan yang sama barulah tampa&

ge:ala J ge:ala timbulnya alergi pada &ulit orang tersebut.?etelah tanda J tanda itu

muncul ma&a antigen a&an mengenali alergen yang masu& yang a&an memicu

a&tifnya sel 8 ,dimana sel 8 tersebut yang a&an merangsang sel B untu&

menga&tif&an antibodi Ig ( . 2roses ini menga&ibat&an mele&atnya antibodi pada

sel mast yang di&eluar&an oleh basofil. #pabila seseorang mengalami paparan untu&

&edua &alinya oleh alergen yang sama ma&a a&an ter:adi % hal yaitu,+

a. @eti&a mulai ter:adinya produ&si sito&in oleh sel 8. ?ito&in memberi&an efe&

terhadap berbagai sel terutama dalam menari& sel J sel radang misalnya netrofil

dan eosinofil, sehingga menimbul&an rea&si peradangan yang menyebab&an panas.

b. #lergen tersebut a&an langsung menga&tif&an antibodi Ig ( yang merangsang

sel mast &emudian melepas&an histamin dalam :umlah yang banya& , &emudian

histamin tersebut beredar di dalam tubuh melalui pembuluh darah. ?aat mere&a

mencapai &ulit, alergen a&an menyebab&an ter:adinya

gatal,prutitus,angioderma,urti&aria,&emerahan pada &ulit dan dermatitis. 2ada saat

mere&a mencapai paru paru, alergen dapat mencetus&an ter:adinya asma. /e:ala

alergi yang paling dita&ut&an di&enal dengan nama anafila&ti& syo&. /e:ala ini

ditandai dengan te&anan darah yang menurun, &esadaran menurun, dan bila tida&

ditangani segera dapat menyebab&an &ematian

. ;"&sifi*&si

Hipe'sensitiit&s &n&fi"&*tif 0 tipe 1

@eadaan ini merupa&an hipersensitivitas anafila&tif se&eti&a dengan rea&si

yang di mulai dalam tempo beberapa menit sesudah &onta& dengan antigen.

Hipe'sensitiit&s sitoto*si* 0 tipe 2


15/23

9ipersensitivitas sitoto&si& ter:adi&alau sistem &e&ebalan secara &eliru

mengenali &onsituen tubuh yang normal sebagai benda asing.

Hipe'sensitiit&s *o!p"e*s i!n 0 tipe %

&omple&s imun terbentu& &eti&a antigen teri&at dengan antibodi dandibersih&an dari dalam sir&ulasi darah lewat &er:a fagositi&.

Hipe'sensitiit&s Tipe "&!)&t 0tipe ,

>ea&si ini yang :uga di&enal sebagai hipersensitivitas seluler, ter:adi %4 hingga

*% :am sesudah &onta& dengan alergen.

4. Ge=&"& ;"inis

#dapun /e:ala &linisnya +

a. 2ada saluran pernafasan + asma

b. 2ada saluran cerna+ mual,muntah,diare,nyeri perut

c. 2ada &ulit+ urti&aria. angioderma,dermatitis,pruritus,gatal,demam,gatal

d. 2ada mulut+ rasa gatal dan pembeng&a&an bibir.

5. Pe!e'i*s&&n Fisi*

Inspe&si + apa&ah ada &emerahan, bentol$bentol dan terdapat ge:ala adanyaurti&aria,angioderma,pruritus dan pembeng&a&an pada bibir

2alpasi + ada nyeri te&an pada &emerahan

2er&usi + mengetahui apa&ah diperut terdapat udara atau cairan

#us&ultasi + mendengar&an suara napas, bunyi :antung, bunyi usus &arena pada oarng

yang menderita alergi bunyi usunya cencerung lebih mening&at.

6. Pe!e'i*s&&n Penn=&n#

U=i *"it + sebagai pemeri&asaan penyaring misalnya dengan alergen hirup seperti

tungau, &apu&, debu rumah, bulu &ucing, tepung sari rumput, atau alergen ma&anan

seperti susu, telur, &acang, i&an.

D&'&- tepi + bila eosinofilia 3! atau 3));ml condong pada alergi. 9itung leu&osit

3)));ml disertai neutropenia "! sering ditemu&an pada alergi ma&anan.


16/23

I#E tot&" &n spesifi*+ harga normal Ig( total adalah )))u;l sampai umur %)

tahun. @adar Ig( lebih dari ")u;ml pada umumnya menun:u&&an bahwa penderita

adalah atopi, atau mengalami infe&si parasit atau &eadaan depresi imun seluler.

8es intradermal nilainya terbatas, berbahaya.

8es hemaglutinin dan antibodi presipitat tida& sensitif.

Biopsi usus + se&under dan sesudah dirangsang dengan ma&anan food chalenge

didapat&an inflamasi ; atrofi mu&osa usus, pening&atan limfosit intraepitelial dan

Ig0. Ig( dengan mi&ros&op imunofluoresen .

2emeri&saan; tes < =ylose, pro&tosigmoidos&opi dan biopsi usus.

ea&si psi&ologi.

19. T-e'&p$/Pen#o)&t&n

#da beberapa regimen diet yang bisa diguna&an +

&. ELIMINATIN DIET7beberapa ma&anan harus dihindari yaitu Buah, ?usu,

8elur, I&an dan @acang, di ?urabaya ter&enal dengan sing&atan B?8I@. 0erupa&anma&anan$ma&anan yang banya& ditemu&an sebagai penyebab ge:ala alergi, :adi

ma&anan$ma&anan dengan inde&s alergenisitas yang tinggi. Inde&s ini mung&in

lain untu& wilayah yang lain, sebagai contoh dengan


17/23

&entang, daging &ambing, &acang merah, buncis, &obis, bawang, formula hidrolisat

&asein, bahan ma&anan yang lain tida& diper&enan&an.

. E!! and FIS FREE DIET:diet ini menying&ir&an telur termasu& ma&anan$

ma&anan yang dibuat dari telur dan semua i&an. Biasanya diberi&an pada

penderita$penderita dengan &eluhan dengan &eluhan utama urti&aria, angioneroti&

udem dan e&sema.e. (IS #N3S DIET7menying&ir&an ma&anan$ma&anan yang di&emu&a&an

sendiri oleh penderitanya sebagai penyebab ge:ala alergi.


18/23


19/23

2asien mengeluh sesa& nafas

% 2asien mengeluh bibirnya beng&a&

" 2asien menga&u tida& ada nafsu ma&an, mual dan muntah

4 2asien mengeluh nyeri di bagian perut

3 2asien mengeluh gatal$gatal dan timbul &emerahan di se&u:ur

tubuhnya.

6 2asien mengeluh diare

* 2asien mengeluh demam.

c. @ronologis &eluhan

2asien mengeluh nyeri perut,sesa& nafas, demam,bibirnya beng&a&,tibul

&emerahan pada &ulit,mual muntah,dan terasa gatal tertahan&an lagi

sehingga pasien dibawa &e rumah sa&it.

>iwayat @esehatan 0asa Calu

0eng&a:i apa&ah sebelumnya pasien pernah mengalami sa&it yang sama

atau yang berhubungan dengan penya&it yang saat ini diderita. 0isalnya,

sebelumnya pasien mengata&an pernah mengalami nyeri perut,sesa& nafas,

demam,bibirnya beng&a&,tibul &emerahan pada &ulit,mual muntah,dan terasa

gatal dan pernah men:alani perawatan di >? atau pengobatan tertentu.

>iwayat @esehatan @eluarga

0eng&a:i apa&ah dalam &eluarga pasien ada;tida& yang mengalami penya&it

yang sama.

>iwayat 2si&ososial dan ?piritual

0eng&a:i orang terde&at dengan pasien, intera&si dalam &eluarga, dampa&

penya&it pasien terhadap &eluarga, masalah yang mempengaruhi pasien,

me&anisme &oping terhadap stres, persepsi pasien terhadap penya&itnya, tugas

per&embangan menurut usia saat ini, dan sistem nilai &epercayaan.


20/23

e. /era& dan a&tifitas

?.

f. >asa 5yaman

?8 +

fa&tor penyebabnya, &ualitas;&uantitasnya, lo&asi, lamanya dan s&ala nyeri.

g. @ebersihan asa #man

?.i. ?osial dan &omuni&asi

? dan ling&ungan

se&itar termasu& terhadap pasien lainnya.

:. 2engetahuan

e&reasi


21/23

o 2emeri&saan neurologist

. Pe!e'i*s&&n Penn=&n#

U=i *"it + sebagai pemeri&asaan penyaring misalnya dengan alergen hirup

seperti tungau, &apu&, debu rumah, bulu &ucing, tepung sari rumput, atau

alergen ma&anan seperti susu, telur, &acang, i&an. D&'&- tepi + bila eosinofilia 3! atau 3));ml condong pada alergi. 9itung

leu&osit 3)));ml disertai neutropenia "! sering ditemu&an pada alergi

ma&anan.

I#E tot&" &n spesifi*+ harga normal Ig( total adalah )))u;l sampai umur %)

tahun. @adar Ig( lebih dari ")u;ml pada umumnya menun:u&&an bahwa

penderita adalah atopi, atau mengalami infe&si parasit atau &eadaan depresi

imun seluler.

8es intradermal nilainya terbatas, berbahaya.

8es hemaglutinin dan antibodi presipitat tida& sensitif.

Biopsi usus + se&under dan sesudah dirangsang dengan ma&anan food chalengedidapat&an inflamasi ; atrofi mu&osa usus, pening&atan limfosit intraepitelial

dan Ig0. Ig( dengan mi&ros&op imunofluoresen .

2emeri&saan; tes < =ylose, pro&tosigmoidos&opi dan biopsi usus.


22/23

%. RENCANA ;EPERAWATAN

&. Po"& n&f&s ti&* efe*tif )e'-)n#&n en#&n te'p&=&n &""e'#en

T=&n 7setelah diberi&an as&ep selama N.x3 menit. diharap&an pasienmenun:u&&an pola nafas efe&tif dengan fre&uensi dan &edalaman rentang normal.

;'ite'i& -&si" 7

Fre&uensi pernapasan pasien normal 6$%) &ali per menit

2asien tida& merasa sesa& lagi

2asien tida& tampa& mema&ai alat bantu pernapasan

8ida& terdapat tanda$tanda sianosis

Intervensi +

@a:i fre&uensi, &edalaman pernapasan dan e&spansi paru. 7atat upaya

pernapasan, termasu& pengguanaan otot bantu; pelebaran masal.

>; + &ecepatan biasanya mening&at. ; + bunyi napas menurun; ta& ada bila :alan napas obstru&si se&under

terhadap pendarahan, be&uan; &olaps :alan napas &ecil atele&tasis. >onci

dan mengi menyertai obstru&si :alan napas; &egagalan pernapasan.

" 8inggi&an &epala dan bantu mengubah posisi. Bangun&an pasien turun dari

tempat tidur dan ambulansi sesegera mung&in.

>; + dudu& tinggi memung&in&an e&spansi paru dan memudah&an

pernapasan. 2engubahan posisi dan ambulansi mening&at&an pengisian

udara segmen paru berbeda sehingga memperbai&i difusi gas.

4 Observasi pola batu& dan &ara&ter secret.

>; + &ongesti alveolar menga&ibat&an batu& &ering atau iritasi. ?putum

berdarah dapat dia&ibat&an oleh &erusa&an :aringan atau anti&oagulan

berlebihan.

3 Beri&an o&sigen tambahan

>; + mema&simal&an bernapas dan menurun&an &er:a napas.

6 Beri&an humidifi&asi tambahan, mis+ nebuli-er ultrasonic.

>; + memberi&an &elembaban pada membran mu&osa dan membantu

pengenceran secret untu& memudah&an pembersihan.

). Hipe'te'!i )e'-)n#&n en#&n p'oses inf"&!&si


23/23

T=&n 7setelah diberi&an as&ep selama N.x.%4 :am diharap&an suhu tubuh pasien

menurun

;'ite'i& -&si" 7

?uhu tubuh pasien &embali normal "6,3oC$"*,3oC

Bibir pasien tida& beng&a& lagi

Inte'ensi+

1 2antau suhu pasien dera:at dan pola .

>; + ?uhu ",$4,7 menun:u&&an proses penya&it infe&sius a&ut.

2 2antau suhu ling&ungan, batasi atau tambah&an linen tempat tidur sesuai

indi&asi

% >;+ ?uhu ruangan;:umlah selimut harus diubah untu& mempertahan&anmende&ati normal.

, Beri&an &ompres mandi hangatG hindari penggunaan alcohol.

>;+

Documents

Nursing in Patient With Food Allergies