ASKEP TOF

SYMPTOM DO: - berat badan 20% atau lebih dibawah berat badan ideal -sesak Ds : -anak menghindari makanan -kurang minat pada makanan -

ETIOLOGI Terpapar faktor eksogen, endogen selama kehamilan Kelainan jantung kongenital sianotik: tof Stenosis pulmonal Obstruksi berat Penurunan aliran darah paru Penurunan O2 dlm darah (diparu) Sesak Anak cepat lelah (makan, minum, beraktifitas Gangguan nutrisi

PROBLEM Ketidakseimbangan nutrisi kurang dari kebutuhan

DX: Gangguan nutrisi kurang dari kebutuhan tubuh b.d ketidakmampuan menelan makanan ditandai dengan berat badan 20% atau lebih dibawah BBI, pasien sesak, menghindari makanan dan kurang minat pada makanan Tujuan: setelah dilakukan tindakan keperawatan selama 2x24 jam nutrisi pasien dapat terpenuhi dengan ktiteria hasil: Nutritional status 1 Nutrient intake Food intake Fluid intake energy Weight/heigh ratio INTERVENSI: nutrition theraphy 2 3 4 5 v v v v v

1. Complete a nutritional assesment, as appropriate 2. Monitor food/ fluid ingested and calculate daily caloric intake, as appropriate 3. Determinan in collaboration with the dietition, the number of calories and type of nutritionts needed to meet nutritiont requirements as appropriate 4. Select nutritional suplement, as appropriate

5. Provide patient with high protein, high calorie, nutritionts finger foods and drinks that can be readily consumed, as appropriate 6. Assist patient to select soft, bland, and nonacidic foods, as appropriate Nutritiont management 1. Weight patient at appropriate intervals 2. Encourage safe food preparation and preservation techniques