Askep Igd Stemi
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ASUHAN KEPERAWATAN GAWAT DARURAT Nama/Usia : Tn. I/ 49 tahun Jenis kelamin : Laki-laki Alamat : Jl. Belitung Darat G.AA, Banjarmasin Nomor register : 1-14-24-XX MRS : 5 Maret 2015 Tanggal Pengkajian : 5 Maret 2015 Diagnosa medis : STEMI + CHF Keluhan : Pasien mengeluhkan sesak dan batuk sejak ± 2 hari yang lalu nyeri pada bagain dada, demam sejak ± 4 hari yang lalu, nyeri tekan pada bagian ulu hati nafsu makan menurun dan kepala terasa pusing. Keadaan Umum : Pasien tampak sesak, pasien tampak meringis sambil memegangi daerah dadanya. PRIMARY ASSESMENT A. AIRWAY (JALAN NAFAS) TEMUAN ANALISA MASALAH PERENCANAAN IMPLEMENTASI WAKTU EVALUASI
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Transcript of Askep Igd Stemi
ASUHAN KEPERAWATAN GAWAT DARURAT
Nama/Usia: Tn. I/ 49 tahunJenis kelamin: Laki-lakiAlamat: Jl. Belitung Darat G.AA, BanjarmasinNomor register: 1-14-24-XXMRS: 5 Maret 2015Tanggal Pengkajian: 5 Maret 2015Diagnosa medis: STEMI + CHFKeluhan : Pasien mengeluhkan sesak dan batuk sejak 2 hari yang lalu nyeri pada bagain dada, demam sejak 4 hari yang lalu, nyeri tekan pada bagian ulu hati nafsu makan menurun dan kepala terasa pusing.Keadaan Umum: Pasien tampak sesak, pasien tampak meringis sambil memegangi daerah dadanya.
PRIMARY ASSESMENTA. AIRWAY (JALAN NAFAS)TEMUANANALISA MASALAHPERENCANAANIMPLEMENTASIWAKTUEVALUASI
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B. BREATHING (NAFAS)TEMUANANALISA MASALAHPERENCANAANIMPLEMENTASIWAKTUEVALUASI
DO: Pasien tampak sesak TD: 110/90 mmHg N: 116 x/mnt RR: 40 x/mnt T: 38,2C SPO2 : 95%DS: Pasien mengeluhkan sesak nafasPasien mengeluhkan nyeri dadaPola nafas tidak efektif b.d ..
C. CIRCULATION (SIRKULASI)TEMUANANALISA MASALAHPERENCANAANIMPLEMENTASIWAKTUEVALUASI
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D. DISABILITY : AVPUTEMUANANALISA MASALAHPERENCANAANIMPLEMENTASIWAKTUEVALUASI
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E. EXPOSURETEMUANANALISA MASALAHPERENCANAANIMPLEMENTASIWAKTUEVALUASI
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SECONDARY ASSESMENT1. Keadaan umum: 2. History:a) S (Signs & Symptom): ..b) A (Allergies): ...c) M (Medication): ..d) P (Past Medical History): .
e) L (Last Meal, Last Menstrual): .f) E (Events): ..3. SubjektifNyeri Dada: tidak terkaji
S: .O: .C: .R: .A: .T: .E: .S: .
Nyeri Abdomen: tidak terkajiP: .Q: .R: .S: .T: .
4. Objektif:Observasi tanda-tanda vital dan SaO2TTV :BP = mmHgHR = x/menitRR = x/menitT = 0CSaO2 =
5. Pemeriksaan Head To Toe:No.BAGIANTEMUAN
1. Kepala
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2.Wajah
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3.Servikalis Dan Leher................................................................................................................................................................................... ................................................................................................................................................................................... ................................................................................................................................................................................... ................................................................................................................................................................................... ................................................................................................................................................................................... ...................................................................................................................................................................................
4.Toraks
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5.Abdomen
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6.Pelvis................................................................................................................................................................................... ................................................................................................................................................................................... ................................................................................................................................................................................... ................................................................................................................................................................................... ...................................................................................................................................................................................
7.Ekstremitas................................................................................................................................................................................. ................................................................................................................................................................................. ................................................................................................................................................................................. ................................................................................................................................................................................. ................................................................................................................................................................................. ................................................................................................................................................................................. ................................................................................................................................................................................. .....................................................................................................................................................................................................................................................................................................................................................................
8. Bagian Punggung................................................................................................................................................................................... ................................................................................................................................................................................... ................................................................................................................................................................................... ................................................................................................................................................................................... .........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
9.Neurologis
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PEMERIKSAAN PENUNJANG 1. LaboratoriumPemeriksaanHasilNilai RujukanSatuanMetoda
HEMATOLOGIHemoglobinLekosit EritrositHematokritTrombositRDW-CV..................
14,00 - 16,004,0 - 10,53,90 5,5037,00 47,00150 45011,5 14,7gr/dLribu/uLjuta/uLvol %ribu/uL%ColorimetricImpedanceImpedanceAnalyzer CalculatesImpedanceAnalyzer Calculates
MCV, MCH, MCHCMCVMCHMCHC............80,0-97,027,0-32,032,0-38,0flpg%Analyzer CalculatesAnalyzer CalculatesAnalyzer Calculates
HITUNG JENISGran %Limfosit %MID %Gran # Limfosit #MID #.....................50,0-70,025,0-40,04,0-11,02,50-7,001,25-4,0
%%%ribu/ uLribu/ uLribu/ uLImpedanceImpedanceImpedanceImpedanceImpedanceImpedance
KIMIAGlukosa darah puasaHatiSGOTSGPTAluminGinjal Ureum KreatininElektrolitNatriumKaliumClorida Faal Lemak Dan JantungLDHCKMB...............4.1............140.73.6106.0
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