Asuhan Keperawtan Pada Pasien Pada Tn (Repaired)

8/18/2019 Asuhan Keperawtan Pada Pasien Pada Tn (Repaired)

1/11

ASUHAN KEPERAWTAN PADA PASIEN PADA TN.B

DENGAN DIC (DISSEMINATED INTRAVASCULAR COAGULATION)

No. Register !!"#

R$%&g Me'%ti

T%&gg%'%* MRS "+ No,e*-er "!/ 0.+

T%&gg%' Pe&g1%i%& "+ No,e*-er "!/

Di%g&os% Me2is DIC

I. Pe&g1%i%&

A. I2e&tit%s

N%*% T&.B

3e&is Ke'%*i& L%1i4'%1i

U*$r +# T%5$&

Ag%*% Is'%*

St%t$s Per1%6i&%& Ni1%5

S$1$B%&gs% 3%6%

Pe1er%%& K%r7%6%&

A'%*%t 3%'%&. Ke*-%&g%& &."

B. Ri6%7%t Pe&g1%i%&

!) Ke'$5%& $t%*%

N7eri 8%2% t%&g%& t%&g%& 2%& ti*-$' -er9%14-er9%1 *er%5 8%2% 1$'it

") Ri6%7%t 1ese5%t%& se1%r%&g

N7eri 2%& 2e*%* 2e&g%& s$5$ ti&ggi :+0;8%sie& seri&g -$%&g %ir 1e9i'

ter$s 2%& *e&ge'$5 *$%' *$&t%5 ;se5i&gg% 8er'$ r%6%t i&%8 2i RS

8%2% t%&gg%' "+ &o,e*-er "!/

+) Ri6%7%t 1ese5%t%& ter2%5$'$Me&2erit% 8e&7%1it gi&%'

#) Ri6%7% 1ese5%t%& 1e'$%rg%

D%ri 1e'$%rg% ti2%1 %2% 7%&g *e&2erit% 8e&7%1it terse-$t %t%$8$&

8e&7%1it '%i&&7%.

4 Ge&ogr%*


2/11


3/11

+. K$'it 2%& *e*-r%& *$1os%

8ere*-es%& 2i=$si 2%r%5 %t%$ 8'%s*%; 8te1i%e; 8$r8$r%

7%&g ter%-% (8%2% %6%'&7% 2i 2%2% 2%& %-2o*e&);

5e*or%gi; 5e*%to*%; '$1% -%1%r 1%re&% 8'ester; si%&osis

%1r%'.

#. Siste* GI

*$%'; *$&t%5; $i g$%i%1 8ositi= 8%2% e*esis%s8ir%si

&%sog%stri1 2%& =eses; &7eri 5e-%t 8%2% %-2o*e&;

8e&i&g1%t%& 'i&g1%r %-2o*e&

/. Siste* $ri&%ri%

5e*%t$ri%; o'ig$ri%

>. Siste* 8er&%=%s%&

2is8&e%; t%1i8&e%; s8$t$* *e&g%2$&g 2%r%5@. Siste* 1%r2io,%s1$'%r

5i8ote&si *e&i&g1%t; 5i8ote&si 8ost$r%'; =re16e&si

%&t$&g *e&i&g1%t; &%2i 8eri=er t%1 ter%-%

0. Siste* s7%r%= 8eri=er

8er$-%5%& ti&g1%t 1es%2%r%&; ge'is%5; 1eti2%st%-i'%&

,%so*otor

. Siste* *$s1$'os1e'et%'

&7eri otot; se&2i 2%& 8$&gg$&g

!. Per2%r%5%& s%*8%i 5e*or%gi i&sisi o8er%si; $ter$s

8ost8%rt$*; =$&2$s *%t% (8er$-%5%& ,is$%')

!!. Prose2$r i&,%si= s$&ti1%&; i,; 1%teter %rteri%' 2%& se'%&g

&%sog%stri1 %t%$ 2%2%; 2%& '%i&4'%i&


4/11

II. ANALISA DATA

N%*% T&. B

R$%&g Me'%ti

No. Reg !!"#

NO D%t% o1$s Eti'ogi M%s%'%5

!.DS P? *e&ge'$5 &7eri 8%2%

t%&g%& t%&g%& 2%& ti*-$' -er9%14

-er9%1 *er%5 8%2% 1$'it.

DO

4P%2% 1'ie& ter'i5%t 8$r8$r%

4P%2% 1'ie& 2ite*$1%& -$'%

5e*or%gi

4P%2% 1'ie& 2ite*$1%& 5e*or%gi

s$-1$t%& 2%& 5e*%to*%

4P%2% 1'ie& 2ite*$1%& s8$t$*

I&=e1si

Se8sis

Ker$s%1%& %ri&g%&

1$'it

Resi1o ter%2i

8e&2%r%5%&


5/11

*e&g%&2$&g 2%r%5

4P%2% 1'ie& ter'i5%t 8er$-%5%&

ti&g1%t 1es%2%r%&

4TTV

• S$5$ +0;/ C

• TD 0/ **Hg

• N%2i !+ ?*e&it

• RR + ?*e&it

e1i*osis

8er2%r%5%&

"

DS

4 K'ie& *e&ge'$5 -$%&g %ir 1e9i'

ter$s

4K'ie& *e&ge'$51%& *$%' 2%&

*$&t%5

DO

4 M$1os% 1eri&g; 8$9%t

4 P%2% 1'ie& 2ite*$1%& 5i8ote&si

*e&i&g1%t 2%& 8ost$r%'

4 K'ie& ter'i5%t &%8%s 9e8%t 2%&2%&g1%'

L$1% -%1%r 2e*%*

2i%8oresis

O$t8$t

De5i2r%si

Reg$'%si 9%ir%& ti2%1

sei*-%&g

De=isit ,o'$*e 9%ir%&

De=isit ,o'$*e 9%ir%&


6/11

4 P%2% 1'ie& 2ite*$1%& ort5o8&e%

4 P%2% 1'ie& 2ite*$1%& =re1$e&si

%&t$&g *e&i&g1%t

4 P%2% 1'ie& 2ite*$1%& &%2i

8eri=er ti2%1 ter%-%

4TTV

• S$5$ +0;/ C

• TD 0/ **Hg

• N%2i !+ ?*e&it

• RR + ?*e&it

III. Di%g&os% 1e8er%6%t%&

N%*% T&. B

R$%&g Me'%ti

No; Reg !!"#

No Di%g&os% Ke8er%6%t%&

!

Resi1o ter%2i 8er2%r%5%& -.2 Pe&$r$&%& =%9tor4=%1tor 8e*-e1$%& 2%r%5

(tro*-osito8e&i)


7/11

"

De=isit ,o'$*e 9%ir%& -.2 8i&2%5&7% 9%ir%& i&tr%,%s1$'er 1e e1str%,%s1$'er.

IV. INTERVENSI N%*% T&. B

R$%&g%& Me'%ti

No.Reg !!"#

T%&gg%' No.

D?

Di%g&os% Me2is NOC NIC

"+

No,e*-

er "!/

! Resi1o ter%2i 8er2%r%5%& -.2

Pe&$r$&%& =%9tor4=%1tor

8e*-e1$%& 2%r%5(tro*-osito8e&i)

De=i&isi

Beresi1o *e&g%'%*i 8e&$r$&%&

,o'$*e 2%t%5 7%&g 2%8%t

*e&gg%&g$ 1ese5%t%&

%1tor resi1o

4A&e$ris*e

4Sir1$*si

4De=isie&si 8e&get%5$%&

B'oo2 'ose

se,erit7

B'oo2

1o%g$'%tio

&

Kriteri% H%si'

4ti2%1 %2%

5e*%t$ri%

41e5i'%&g%& 2%r%5

7%&g ter'i5%t

4te1%&%& 2%r%5

B'ee2i&g

8re9%$tio&

4*o&itor 1et%t

t%&2%4t%&2%

8er2%r%5%&

49%t%t &i'%i H-

2%& HT

se-e'$* 2%&

ses$2%5

ter%2i&7%

8er2%r%5%&4*o&itor &i'%i


8/11

4tr%$*%

4E=e1 s%*8i&g ter1%it ter%8i

(*is.;8e*-e2%5%&;8e*-eri%&

o-%t;8e*-eri%& 8ro2$1 %2%r%5

2e=ise&si tro*-osit;1e*oter%8i)

2%'%* -%t%s

&or*%' sisto' 2%&

2i%sto'

45e*og'o-i& 2%&

5e*%tro1rit 2%'%*

-%t%s &or*%'

48'%s*%;PT;PTT

2%'%* -%t%s

&or*%'

'%-(1o%g$'%si)

7%&g *e'i8$ti

PT;PTT;tro*-

osit

4Mo&itor

TTV

ortost%ti1

48ert%5%&1%&

-%2 rest

se'%*%

8er2%r%5%&

%1ti= "+

No,e*-

er "!/

" 1e1$r%&g%& ,o'$*e 9%ir%&

-.2 8i&2%5&7% 9%ir%& i&tr%,%s1$'er

1e e1str%,%s1$'er.

De=i&isi

Pe&$r$&%& 9%ir%& i&tr%,%s1$'%r;

i&tertisi%'; 2%& %t%$ i&tr%se'$'er.

I&i *e&g%9$ 8%2% 2e5i2r%si;

1e5i'%&g%& 9%ir%& s%% t%&8%

8er$-%5%& 8%2% &%tri$*.

B%t%s%& 1%r%1teristi1

48e&$r$&% te1%&%& 2%r%5

48e&$r$&%& te1%&%& &%2i

48e&$r$&%& t$rgor 1$'it

48e&$r$&%& t$rgor 'i2%5

4*e*-r%& *$1os% 1eri&g

48e&i&g1%t%& 5e*%to1rit

48e&i&g1%t%& s$5$ t$-$5

4 1e'e*%5%&

%1tor 7%&g -er5$-$&g%&

41e5i'%&g%& 9%ir%& %1ti=

4Keg%g%'%& *e1%&is*e reg$'%si

'$i2

-%'%&9e

H72r%tio&

N$tritio&%'

st%t$s

=oo2 %&2

='$i2

I&t%1e

Kriteri% H%si'

4*e*8ert%5%&1%

$ri&e o$t8$t

ses$%i 2e&g%&

$si% 2%& BB; B3

$ri&e &or*%'; HT

&or*%'

4te1%&%& 2%r%5;

&%2i; s$5$ t$-$5

2%'%* -%t%s

&or*%'

4ti2%1 %2% t%&2%

t%&2% 2e5i2r%si

4e'%stisit%s t$rgor

1$'it -%i1;

'$i2

*%&%ge*e&t

48ert%5%&1%&

9%t%t%& i&t%1e

2%& o$t8$t

7%&g %1$r%t

4*o&itor

st%t$s 5i2r%si

(1e'e*-%-%&

*e*-r%&

*$1os%; &%2i

%2e1$%t;te1%&

%& 2%r%5

ortost%ti1);

i1%

2i8er'$1%&

4*o&itor ,it%'

sig&

4*o&itor

st%t$s &$trisi

41%'%-or%si

2e&g%& 2o1ter

H78o,o'e*i%

M%&%ge*e&t


9/11

*e*-r%& *$1os%

'e*-%-; ti2%1 %2%

r%s% 5%$s 7%&g

-er'e-i5%&

4*o&itor

st%t$s 9%ir%&

ter*%s$1

i&t%1e 2%&

o$t8$t 9%ir%&

4*o&itor

ti&g1%t H-

2%&

5e*%to1rit

V. IMPLEMENTASI

N%*% T&. B

R$%&g%& Me'%ti

No.Reg !!"#

T%&gg%' No.

D?

3%* I*8'e*e&t%si P%r%=

"+!!!/ ! 0.+

.+

!.

4*e*o&itor 1et%t t%&2%4t%&2% 8er2%r%5%&

4*e&9%t%t &i'%i H- 2%& HT se-e'$* 2%&

ses$2%5 ter%2i&7% 8er2%r%5%&

4*e*o&itor &i'%i '%-(1o%g$'%si) 7%&g *e'i8$ti

PT;PTT;tro*-osit

4Me*o&itor TTV ortost%ti1

4*e*8ert%5%&1%& -%2 rest se'%*% 8er2%r%5%&

%1ti=

"+!!!/ " !!.

!".

!+.

4*e*8ert%5%&1%& 9%t%t%& i&t%1e 2%& o$t8$t

7%&g %1$r%t

4*e*o&itor st%t$s 5i2r%si (1e'e*-%-%&

*e*-r%& *$1os%; &%2i %2e1$%t;te1%&%& 2%r%5

ortost%ti1); i1% 2i8er'$1%&

4*e*o&itor ,it%' sig&

4*e*o&itor st%t$s &$trisi

4-er1%'%-or%si 2e&g%& 2o1ter 2%'%* 8e*-eri%&

t5er%8i


10/11

VI. EVALUASI

N%*% T&. B

R$%&g%& Me'%ti

No.Reg !!"#

T%&gg%' No.

D?

E,%'$%si

"+!!!/ ! S P? *%si5 *e&ge'$5 &7eri 8%2% t%&g%& 2%& *%si5 ti*-$' -er9%14 -er9%1 *er%5 8%2% 1$'it&7%.

O 4 P%2% 1'ie& 2ite*$1%& s8$t$* *e&g%&2$&g 2%r%5

4 P%2% 1'ie& ter'i5%t 8er$-%5%& ti&g1%t 1es%2%r%&

4 TTV

• S$5$ +0;/ C

• TD 0/ **Hg

• N%2i !+ ?*e&it

• RR + ?*e&it

A Resi1o ter%2i 8er2%r%5%& -e'$* ter%t%si

P I&ter,e&si 2i'%&$t1%&

"+!!!/ "

S P? *%si5 *e&ge'$5 -$%&g %ir 1e9i' ter$s *e&er$s 2%& *%si5

*e&ge'$51%& *$%' 2%& *$&t%5


11/11

O 4 M$1os% P? *%si5 1eri&g; 8$9%t

4 *%si5 2ite*$1%& 5i8ote&si *e&i&g1%t 2%& 8ost$r%'

4 P? ter'i5%t &%8%s 9e8%t 2%& 2%&g1%'

4 *%si5 2ite*$1%& =re1$e&si %&t$&g *e&i&g1%t

4TTV

• S$5$ +0;/ C

• TD 0/ **Hg

• N%2i !+ ?*e&it

• RR + ?*e&it

A Ke1$r%&g%& ,o'$*e 9%ir%& -e'$* ter%t%si

P I&ter,e&si 2i'%&$t1%&

Asuhan Keperawtan Pada Pasien Pada Tn (Repaired)

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