Asuhan Keperawatan Pada Pasien Tn m

8/15/2019 Asuhan Keperawatan Pada Pasien Tn m

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ASUHAN KEPERAWATAN PADA PASIEN Tn M

DENGAN HEPATOCELLULER CARSINOMA (HCC) DI RAUNGPENYAKIT DALAM PRIA RSUD ULIN BANJARMASIN

A. Pengkajan

I. ! Da"a S#$%ek"&

A. IDENTI'IKASI

A.!. Inen"&ka Paen Na*a + Tn. M

U*#, + -- Ta#n

Aga*a + I/a*

Penkan + SD

Peke,jaan + S0a"a

S"a"# Pe,ka0nan + Ka0n

S#k#1Banga + Banja,1In2nea

Dagn2a Me + HCC (He3a"24e//#/e, Ca,n2*a)Tangga/ MRS + 5678-758!9

Tangga/ Pengkajan + !-78:758!9

N2. Reg",a + !.!-.!:.6;

A/a*a" + J/. Peka3#,an Ra%a Gg. S0aa%a R".!!

A.!. Inen"&ka Penangg#ng Ja0a$

Na*a + N%. A

U -8 T


2/14

U -8 T

ka,ak"e,"k n%e,n%a %a"# n%e, %ang e$e$kan ka,ena 3e*$ea,an 2,gan a"=

k#a/"a n%e, e3e," "e,$aka,1,aa 3ana 3e,#= ae,a n%e,n%a *#ka an 3e,#" $agan kana a"a *en%e$a$kan ke 3#ngg#ng ngga aa= ka/a n%e,n%a > a,

ka/a !7!8= an 0ak"# /ang7"*$#/

D. R0a%a" keea"an %ang /a/#

Paen *enga"akan a *ene,"a 3e"" B k,2n= ek"a, $#/an %ang /a/a#

3en%ak" 3aen e,ng ka*$# an #/# a" "e,aa ak" j#ga 3e,# e$e/akanann%a= ka,ena 3en%ak"n%a "ak $e,3enaganan/e$ /anj#" 2/e 3aen

ak,n%a 3aen *enge/a* *#n"a a,a ngga 3aen $a0a ke ,#*a ak".

E. R0a%a" keea"an ke/#a,ga

Paen *enga"akan a, ke/#,gan%a "ak aa *ene,"a 3en%ak" a*a e,"an%=

ke/#,aga 3aen j#ga "ak *enga/a* 3en%ak" *en#/a, e3e," e3a""= HI? an 3en%ak" ke"#,#nan e3e," 3e,"en= 3en%ak" jan"#ng j#ga "ak aa.


3/14

a/a* 3,2e 3en%e*$#ann%a= 3aen $e,a,a3 aga, 3en%ak"n%a $a e*$# an 3aen

"ak /ag *e,aa "ak /ag *e,a keak"an 3aa 3e,#"n%a engga "ak *enggangg#ak""a *a#3#n ",aa" 3aen.

'. P2/a ke$aaan ea,7a,

N2. P2/a ke$aaan Se$e/#* *a#k RS Se#a *a#k RS

a.

$.

N#",

!. Makanan7 ',ek#en

7 Jen

7 A/e,g

7 Ke/#an

5. Mn#*an

7 J#*/a7 Jen

7 Ke/#an

E/*na

!. BAK

7 ',ek#en

7 Jen

A/e

- 1 a,

Na ge/a1 3e,a,A, 3#"1 "e

7

:79 1 a,

>9 44

K#nng

- 1 a, !!15 32,

B#$#, < /a#k 3a#k

7

Jka n%e, a"ang= !

"ak na&# *akan

97; ge/a13e,a,A, 3#"

7

: 1 a,

988 44

K#nng ke42k/a"an


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.

e.

&.

7 *eng#nakan

7 ke/#an

S3,"#a/

7 &,ek#en

7 ke/#an

Ak""a an /a"an

7 3e,ge,akan7 ka/a ak"&"a

7 ka/a 2"2"

7 /a"an

7 ke/anan

7 ke/#an

ek#a/"a ,e3,2#k

7 ke/#an

9 1 a,

7

Be$a

!

9 9

9 9

7

7

7

7

7S#a $e,ak""a ka,ena

n%e,

Te,$a"a

-

: :

- -

7

7

S#a $e,ka"&"a ka,ena

n%e,

7

I.5 Da"a Ok%ej"&

A. Keaaan U*#*

!. Keaaan Paen + Paen "a*3ak /e*a an "e,$a,ng "e*3a" "#,


5/14

*engg#nakan a/a" $an"# 3enge/a"an "ak aa gangg#an 3aa 3aen

aa" *e/a".:. Pen4#*an an #ng + ng 3en4#*an n2,*a/ 3aa 3aen= "ak

aa #*$a"an 3aa #ng 1 ja/an na3a= "ak aa 3e,aangan 3aa

#ng= "e,3aang 25 0aa#/ kan#/ engan keen",a : /3* 3aa 3aen

an 3aen *enge/# eak na3a.

9. Penenga,an an "e/nga F "e* 3enenga,an 3aen n2,*a/= "ak aa

4a,an 3aa "e/nga 3aen= "e/nga ke/a"an $e,= "ak aa ke/#a,

4a,an 3aa "e/nga 3aen

;. M#/#" an gg + keaaan 3aen "e,/a" k2"2,= ng 3en4e,naan

$agan a"a $ak= 3aen a3a" *ene/an an *eng#n%a *akanan= gg

3aen /engka3= "ak aa 3e,aangan 3aa *#/#" *a#3#n gangg#an

/an%an%a.

>. Daa= 3e,na3aan an ,k#/a F n3ek + "e,a3a" ,e",ak ng

aa= 3,ean 3a,# "e,$a"a= 3aeen *engg#nakan 2"2" a$2,#3n

4,a"$e,na&a 3a/3a + ng aa *e",= "ak"/ &,e*"# "e,a$a==

"ak aa n%e, "ekan a3a aa = en%#" jan"#ng "e,a$a 4 :=

3,ek#en F #a,a 3a,# aa" 3e,k#j2n2,1,e2nan 3aa aa e$e/a

k k k / & k /


6/14

n ,/ 58 "3*= ke*a*3#an 3aen a/a* *2$/a $e,ge,ak $an"# 2/e

ke/#a,ga.Kek#a"an 2"2" ka/a ak"&"a @ "ngka" -

Ke" + ka/a 2"2 : @ *a*3# *enge,akan

Pe,enan engan ga%a

g,a"a= an *a*3# *e/a0an

engan "aanan eang.

Ska/a 2"2" - @ an%a *a*3#

*engge,akan 3e,enan *e/a0an

g,a&"a= *a*#n "ak *a*3#

*e/a0an engan "aanan

!8. Gen"a//a + 3aen $e,jen ke/a*n /ak7/ak= 3aen "e,3aang ka,ak"e,

e. Da"a 3en#njang

Pe*e,kaan Ha/ N/a ,#j#kan Sa"#an

He*2k/2$n

Le2k2e"

E,",2"

H2*2"2k,"

!8=8

6=8

-=6

-5=:

!:.887!6.88

:.87!8.9

:.987;.88

:5.88795.88

11

T$#1#1

J#"a1#1

√ 8!

Ke" + Ska/a ak"&"a "ngka" - @

3aen *e*e,/#kan

$an"#an an 3enga0aan

2,ang /an engan

$*$ngan ee,ana

: :

- -


7/14


8/14

7 Paen *enge/# "ak $a "#,

3aa ang ana *a/a* a,engan n%en%ak= 3aen an%a

"#, < 5 ja* aja ka,ena n%e,

3aa 3e,#".

7 Paen *enge/# #/" *e/ak#kan

ak"&"a ka,ena n%e,

7 Paen *enge/# eak na&a.

7 Te,a3a" 2/e*a 3aa ke#a

ek",e*"# $a0a e,"a "ng23e*a

7 Ke*a*3#an 3aen $e,ge,ak $an"#

2/e ke/#a,ga

7 Ska/a 2"2 : : = ka/a ak"&"a @

- -

"ngka" -

7 A'P!888= A/$#*n@5=9 $/,#$n

,ek@8=;6 *g/= $/,#$n n,ek

@ 8.!: *g11 SG8!1SGPT

!:8158>1#1!

7 K#/" an k/e,a 3aen $e,0a,na

kek#nng7k#nngan 1k"enk

Ana/ a"a


9/14

D2gn2ake3e,a0a"an

N2 Da"a E"2/2g Maa/a

!. D @ Paen *enge/# n%e,

3aa 3e,#" $agan kanan n%a=

engan ka,ak"e,"k n%e,

%ang e$a$kan 2/e

3e*$ea,an 2,gan a"= engan

k#a/"a n%e, "e,aa

"e$aka,13ana 3aa 3e,#"=

"e*3an%a 3aa $agan kann a"a

an $agan $a0a a*3a ke

3#ngg#ng ke*#an *en%e$a,

ke aa= ka/a n%e, $e,a" > a,

(!7!8) an 0ak"# n%e,n%a

/ang "*$#/.

DO @ Paen "e,/a" *e,ng

keak"an e,"a *e*egang

3e,#n%a ka,ena *enaan n%e,=

3aen "a*3ak /e*a an

"e,$a,ng "e*3a" "#,=

"e,a3a" a"e 3aa $agan

k k " $

Agen

4e,a$2/2g

N%e, ak#"


10/14

!. N%e, ak#" $e,#$#ngan engan agen 4e,a$2/2g

5. P2/a na&a "ak e&ek"& $e,#$#ngan engan ek3an 3a,# "e,gangg#

ka,ena a"e

-. In"2/e,an ak"&"a $e,#$#ngan engan ke/e*aan

:. Ke/e$an 2/#*e 4a,an $e,#$#ngan engan a"e an 3e*$en"#kan


11/14

In"e,en Ke3e,a0a"an

No Diagnosa Tujuan dan KH Intervensi Rasional

!.

5.

N%e, ak#" $.

agan42,a $2/2g

P2/a na&a "ak e&ek"&

$. 3en#,#nan ek3an

3a,# ka,ena a"e.

Se"e/a /ak#kan "nakan !; ja*

a,a3kan n%e, 3aa 3aen

$e,k#,ang 1/ang

Dengan k,e"e,a a/

7 Paen na*3ak "enang=0aja

3aen "ak *e,ng keak"an=

ka/a n%e, -78= TT? R3@!67

!:1*en"= HR@687!88 1*en" =

T@-;=97->=9 24 TO !-8168= 3aen

a3a" *e*anaje*en n%e,n%a.

Se"e/a /ak#kan *nakan

ke3e,a0a"an ! ; ja* a,a3kan

32/a na3a ke*$a/ e&ek"& = engan

k,"e,a a/

Dengan k,e",a a/

7 Pe,ge,akan 3aa n2,*a/

7 Pengg#naan 2"2" $an"# 3e,na3aan

$e,k#,ang7 S#a,a 3a,# $e,

7 Paen "ak e,aa eak

!. K2/a$2,a engan "* *en

/an a/a* 3e*$e,an ana/gek

#n"#k *eng#,ang n%e,.

5. Be,kan 322 en%a*an

*#ngkn-. Be,kan "nakan ken%a*anan

aa, *a/n%a ,e32= g22k

3#ngg#ng:. Lak#kan 3engkajan n%e, a4a,a

k2*3,een& "e*a#k /2ka=

ka,ek"e,"k= #,a= &,ek#en=

k#a/"a an &ak"2, 3,e3ka

!. Be,kan 2kgen e#a a a,

2k"e,

5. P2kan 3aen ea #3 -8

3a e* 32e/e,

-. Aja,kan "aknk ,e/aka:. Pan"a# 32/a 3e,na3aan=

a#k#/"a #a, na&a

9. Pan"a# T

!. Un"#k *eng#,ang 1*eng/angkan

,aa n%e,

5. Me*$e,kan ,aa n%a*an 3aa

3aen engga n%e, $e,k#,ang

-. Menngka"kan ,e/aka an*e*$an"# *e*&2k#kan ke*$a/

3e,a"an

:. Un"#k *enge"a# "ngka" ken",an

3aen an ka,ek"e,"k n%e,n%a

!. Me*#akan 3aeen a/a*

$e,na3a

5. Meng23"*a/kan 3e,na3aan

-. Un"#k *e*3e,$ak 32/a

3e,na3aan:. Menge"a# "nak e/anj#"n%a %ang

akan /ak#kan e,"a *enge"a#

aan%a #a,a "a*$aan

9. Un"#k *enen"#kan an *en4ega

k2*3/"ka

No Diagnosa Tujuan dan KH Intervensi Rasional


12/14

-.

:.

In"2/e,an ak"&"a $.

ke/a*aan

Ke/e$n 2/#*e 4a,an

$. an 3e*$en"#kan

ee*a

Se"e/a /ak#kan "nakan

ke3e,a0a"an ! ; jan= a,a3kan 3aen a3a" *e/ak#kan

1*enngka"kan ak"&"a=engan k" +

7 Ke*$a/ $a

7 Se/e,a n2,*a/

7 K2nj#k"a n2,*a/

7 Paen a3a" *e/ak#kan ka"&"a

ak"&"a ,ngan7 T,# DBN

Se"e/a /ak#kan "nakan

ke3e,0a"an ! ; ja*= a,a3kan

3aen $ang#n ?O/ 4a,an 3aen

*enja e*$nag= engan k,"e,a

a/+

7 Mengk#" e" ,ena na",#* an 3e*$a"aan 4a,an e3e," %ang

n",/kan

7 Mengg#nakan #,e"k= #3e/*en

ka//##n an 3,2"en e#a nka

7 E*a an a"e $e,k#,ang

!. K2/a$2,a engan "* *e

a/a* 3e*$enan "e,a3 nean 2$a" #"e"k

5. Be,kan /ngk#ngan "enang $a"a

3eng#nj#ng an k#,ang #a,a

$ng an 3e,"aankan ",a

$enng $/a nkakan

-. Anj#,kan 3aen ",aa" $/a

"eja ke/e/aan an ke/a*aan=anj#,kan 3aen *e/ak#kan

ak"&"a e*a*3#n%a

:. O$ea TI? e$e/#* an

e#a ak"&"a

9. O$ea ke/angan 1 gangg#ankee*$angan ga%a ja/an an

ke/e*aan 2"2"

!. K2/a$2,a a/a* 3e*$e,an 2$a"

#,e"k= an 2$a" #n"#k

3enngka"kana$#*n e#a a,an

2k"e,

5. Ba"a a#3an na",#* an 4a,an

jka n",#kkan-. Ca"a a#3an an a/#a,an 4a,an

:. Je/akan ,a2na/ 3e*$a"aan

na"",#* an 4a,an

!. Menggan" 4a,an an e/ek",2/"

e4a,a a#ka"& an *eng#,ang 3e*$engkakan *e/a/# k,e 2/e

3en#*3#kan 4a,an

5. Menngka"kan ",aa" #n"#k

*en#,#nkan ke$#"#an 25 "#$# an

*en#,#nkan "egangan "#/ang an

3a,#

-. *enngka"kanak""a $e,"aa3a*3a n2,*a/ an *e*3e,$ak

"2n# 2"ak

:. *an3e"a ka,2 &2,*2na/ a,

#3a%a jan"#ng an 3a,# #n"#k

*e*$a0a j#*/a 25 aek#a" ke janngan

9. *en#nj#kan aan%a 3e,#$aan

ne#,2/eg% ka,ena e&een "a*n

$!5 *e*3enga,# kea*a*an

3aen1 ,ek2 4ee,a

!. *enngka"kan ek"e 4a,an /e0a"

gnja/ an *e*3e,a"kan

kee*$angan 4a,an e,"a e/ek",2/"

%ang n2,*/a

5. *e*n*a/kan 3e*e$en"#kan a/

an ee*a-. *en/a e&ek"&"a "e,a3 an

ke4#k#3an a#3an 4a,an

:. *engngka"kan 3e*aa*an an

ke,jaa*a 3aen a/a* *enja/an

an *e/akanakan 3e*$a"aan

4a,an


13/14

I*3,/e*"a Ke3e,a0a"an

No Hati/ Tanggal Doagnosa Jam Implemantasi Jam Evaluasi Tindakan

!.

5.

Senn1!-78:758!9

Senn1!-78:758!9

N%e, ak# $. agan

4e,a $2/2g

P2,a na&a "ak

e&ek"& $.

3eng#,angan

ek3an 3a,#

ka,ena a"e

8:.8

8

8.8

8

!. $e,k2/a$2,a engan *e /an a/a*

*e*$e,kan ana/gek #n"#k *eng#,ag

n%e,

o nj e"2,2/a" -! an #,agek 3a"4

5. *e*$e,kan 32 en%a*an *#ngkn

o 32 ##k "engk#,a3 engan a"a

$an"a/ 3aa ae,a an"a,a 3e,#" an aa-. *e*32kna 3aen jka n%e, #a

$e,k#,ag an *enaj#kan ke/#a,ga #n"#k

*eng22k 3#ngg#ng 3aen

o 32 #3na= 3aen *e,aa n%e,

ek" $e,k#,ang

:. *e/ak#kan 3engkajan n%e, e,"a

k2*3,een&

P @ n%e, %ang e$a$kan 2/e 3e*$ea,an

2,gan a"1e3e,.

@ k#a/"a n%e, 3e," "e,$aka,13ana

ae,a 3e,#"R @ "e*3a"n%a 3e,#" kanan a"a ngga

3#ngg#ng an *en%e$a, a*3a ke

aaS @ ka/a n%e, > (!7!8)

T @ H/ang T*$#/

!. Me*$e,kan O5 e#a a 2k"e,

o O5 $e,kan 4a *aa/ kan#/ engan

k2n : /3*

5. Me*32kan 3aen e* 320/e, -. Mengaja,kan "eknk ,e/aka

:. Menga#kan "e $#n% na&a 3aen

9. Me*an"a# TT?

TD + !:8168 **g PR @ -; 1*en"

M @ 8 1*en" Te*1+ -;=> 24

!:.8

8

S + 3aen *enga"akan n%e, 3e,#n%a *#/a

$e,k#,ang an *e,aa n%a*an . n%e,n%a

"e,a 3ana1"e,$aka, 3aa $agan 3e,#"=

"e*3a"n%a 3aa 3e,#" kanan $agan

$agan a"a ngga 3#ngg#ng an

*en%e$a, ke aa= ka/a n%e, 9 (eang)

a, (!7!8)= %e, n%a /ang "*$#/

O + 3aen *#/a "e,/a" "enagn "ak ge/a

/ag= 0aja 3aen *a *eng

keak"an na*#n "ak *e*egang

3e,#"n%a /ag

A + *aa/ $e/#* "e,a"a

I + /anj#"kan In"e,en != 5= -= :

S + Paen *enga"akan *a *e,aa eak

na*#n "ak e3e," e$e/#*n%a eak

eka/

O F "e,a3a" ,e",ak ng aa= 3engg#ngan

2"2 a$2*en a/a* $e,na&a= $#n% na&a

,2n4

TT? @TD @ !-81>8 RP @ 58 C*

N @ 61* T @ -;=>24

A + *aa/a $e/#* "e,a"a

P + /anj#"kan In"e,en != 5= -= : an ;

No Hati/ Tanggal Doagnosa Jam Implemantasi Jam Evaluasi Tindakan


14/14

-.

:.

Senn1!-78:758!9

Senn1!-78:758!9

In"2/e,an ak"&"a

$. 3aen

Ke/e$an 2/#*e

4a,an $e,g#$#ngan

engan

8.8

8

8.8

8

!. $e,k2/a$2,a engan *e a/a*

*e*e$e,kan "e,a3 n,#e an 2$a" #,e"k

o I?'D RC F DS !8 "e*

'#,2 e*e 5.578

5. *e*$e,kan /ngk#ngan %ang "enang #n"#k

3aen= an *e*3e,"aankan #a $a,nge/a*a ke/e*aan

-. *engaj#,kan 3aen *e/ak#kan ak"&"a,a

e*a*3#n%a an ",aa" e"e/a *#/a*e,aa /e/e

:. *eng2$e,akan TT? e$a/#* an

e#a ak"&"a TD + !:81688 RP + -; 1*

N + :1* T + -;=> 24

9. *eng2$ea ke/angan 1gaangg#an

kee*$angan ga%a ja/an an ke/e*aan

2"2" .

o 3aen $e,#aa "e"a3 "ak *a*3#

*en%e*$angkan aa" $e,ja/an

!. $e,k2/a$2,a a/a* *e*$e,kan 2$a"#"e"k an 2$a" #n"#k 3enngka"kan

a/$#*n e#a a,an 2k"e,

7 ,2e* 5.578 (nj)

P.O ?IP a/$#*n - 5

5. *e*$a"a a#3an n#",#* an 4a,an

7 3aen anj,kan #n"#k e" ,ena

*a",#* an *e*$a"a *n#* $an%ak

-. *en4a"a" a#3an an a/#a,an #,n

n3#" + >98 44 O#"3#" + 988 44

:. *enje/akan ke3aa 3aen kena3a

/ak#kan 3e*$a"aan na",#* an 4a,an

3aen 3aa* an *enge," %angej/akan 3e,a0a"

!:.8

8

S + 3aen *enga"akan $aan%a *a /e*a

an $e/#* $a *e/ak#kan ak"&"ae3e," $aa

O + 3e,ge,akan en *a "e,$a"a= k.#

/e*a 3 an%a $e,$a,ng "e*3a"n%a

"#, A/ $an"# 2e/ ke/#a,ga

TT? + !D !-81>8 RP + 56 1*

H, + 6 * T + -;=>2

4

A + *aa/a $e/#* "e,a"a

I + /anj#"kan In"e,en != 5= -= : an 9

S + Paen *enga"akan 3aa kakn%a *a

"e,a3a" $engkak

O +"ea3a" a/2* 3aa ek",e* "a $a0a

kanan an k,7 7 = P""ng O/e* (

Asuhan Keperawatan Pada Pasien Tn m

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