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YAYASAN EKA HARAP PALANGKA RAYA

SEKOLAH TINGGI ILMU KESEHATAN

Jl. Beliang No. 110 Palangka Raya Tel ! "a# $0%&'( &))**0*

"ORMAT ASUHAN KEPERA+ATAN ME,IKAL BE,AH

Nama Mahasiswa :Chaterine Claudia Sandra (2014.B.15.0364)

Intan usuma !a"rian# (2014.B.15.03$3)

%uslia !e"r# (2014.B.15.03$6)

&ia Sa'utri (2014.B.15.031)

i*+ Suant+ (2014.B.15.03,4)

iswan Sa'utra (2014.B.15.03,6)

-ahwani (2014.B.15.0400)

NIM : .

uan/ ra*te* : ahlia

an//al ra*te* : .

an//al %am en/*aian : $ %anuar# 2016

I. PENGKAJIAN

A. I,ENTITAS PASIEN

Nama : Mr. %

mur : 20 #ears +ld

%enis elamin : Male

Su*uBan/sa : a#a*Ind+nesia

7/ama : 8indu

e*eraan : Student

endidi*an : SM7

Status er*awinan : Sin/le

7lamat : %l. Man//a

/l MS : 4 %anuar# 2016

ia/n+sa Medis : 7stma Br+n9ial

B. RI+AYAT KESEHATAN !PERA+ATAN

1. eluhan tama :

atient sa# its hard t+ "reathe.

2. iwa#at en#a*it Se*aran/ :

!amil# said the 'atient has di;;i9ult# "reathin/ less than tw+ m+nths.

3. iwa#at en#a*it Se"elumn#a (riwa#at 'en#a*it dan riwa#at +'erasi)

N+thin/

4. iwa#at en#a*it eluar/a

i h di ; hi h



GENOGRAM KELUARGA -

eteran/an:

eath

Male

!emale

atient

&i;e +/ether

. PEMERIKSAAN "ISIK

1. Kea/aan U -

C+m'+s mentis 'atients 9+nditi+n. atients use a "lan*et< atta9hed in;usi+n +; NaCl in

the le;t hand.

). S2a23 Men2al -

a. in/*at esadaran : C+m'+s Mentis

". =*s'resi waah : .

9. Bentu* "adan : .

d. Cara "er"arin/"er/era* : .

e. Ber"i9ara : .

;. Suasana hati : .

/. enam'ilan : .

h. !un/si *+/niti; :

• >rientasi wa*tu : .

• >rientasi >ran/ : .

•

>rientasi em'at : .

i. 8alusinasi : en/ar7*usti9 &ihat?isual &ainn#a .........

. r+ses "er'i*ir : Bl+9*in/ Cir9umstansial !li/ht +h ideas

&ainn#a



m. Me*anisme 'ertahanan diri : 7da'ti; Malada'ti;

n. eluhan lainn#a : .

&. Tan/a4Tan/a 5i2al -

a. Suhu : .0C 7@illa e*tal >ral

". Nadi8 : @mt

9. erna'asan : ....@tm

d. e*anan arahB : .....mm 8/

6. PERNAPASAN $BREATHING(

Ben2k ,a/a - Sie27i3

Ke8ia3aan e7okok - 4 Ba2ang!9a7i

Ba2k: 3e;ak there is no

Ba2k /a7a9: 3e;ak................................................there is no

S2: <a7na......................................................there is no

Siano3i3 there is no

Nye7i /a/a Exist

,y3noe nye7i /a/a O729onoe Lainnya ==.===..

Se3ak na>a3 Saa2 in3i7a3i Saa2 ak2i?i2a3 Saa2 i32i7a9a2

Tye Pe7na>a3an ,a/a Pe72 ,a/a /an e72

K3al 9eyne432oke3 Bio2

Lainnya

I7aa Pe7na>a3an Te7a27 Ti/ak 2e7a27

Sa7a Na>a3 5e3kle7 B7on@9o?e3ikle7

B7on@9ial T7akeal

Sa7a Na>a3 2a8a9an +9eeing Ron@9i ke7ing

Ron@9i 8a3a9 $7ale3( Lainnya=====

Kel9an lainnya -

...............................................................................................................................

...............................................................................................................................

...............................................................................................................................

Ma3ala9 Kee7a<a2an -

...............................................................................................................................

...............................................................................................................................

%. AR,IO5ASULER $BLEE,ING(

N#eri dada ram *a*i u9at

usin/sin*+' Clu"in/ ;in/er Sian+sis

Sa*it e'ala al'itasi in/san



NerDus ranial ? : ..........................................................................................

NerDus ranial ?I : ..........................................................................................

NerDus ranial ?II : ..........................................................................................

NerDus ranial ?III : ..........................................................................................

NerDus ranial IE : ..........................................................................................

NerDus ranial E : .........................................................................................

NerDus ranial EI : ..........................................................................................

NerDus ranial EII : ..........................................................................................

i ++rdinasi :

=*strimitas 7tas : %ari *e ari +siti; Ne/ati;

%ari *e hidun/ +siti; Ne/ati;

=*strimitas Bawah : umit *e em'ul *a*i +siti; Ne/ati;

i esta"ilan u"uh : +siti; Ne/ati;

e;le*s :

Bise' : anan FG iri FG S*ala.

rise' : anan FG iri FG S*ala.

Bra*i+radialis : anan FG iri FG S*ala.

atella : anan FG iri FG S*ala.

7*hiles : anan FG iri FG S*ala.e;le*s Ba"ins*i anan FG iri FG

e;le*s lainn#a : ..........................................................................................

i sensasi : ..........................................................................................

..........................................................................................

eluhan lainn#a :

...............................................................................................................................

...............................................................................................................................

...............................................................................................................................

Masalah e'erawatan :

...............................................................................................................................

...............................................................................................................................

*. ELIMINASI URI $BLA,,ER( -

r+du*si rine : .ml@hr

-arna :

Bau :

id * d l hl M t I * ti



+liuri anas 8ematuri

#suri N+9turi

ateter C#st+st+mi

eluhan &ainn#a :

...............................................................................................................................

...............................................................................................................................


...............................................................................................................................

...............................................................................................................................

. ELIMINASI AL5I $BO+EL( -

Mulut dan !arin/

Bi"ir : ...................................................................................................

i/i : ...................................................................................................

usi : ...................................................................................................

&idah : ...................................................................................................

Mu*+sa : ...................................................................................................

+nsil : ...................................................................................................

e9tum :

8aem+r+id :

B7B : .@hr -arna :.. . +nsistensi : .

ida* ada masalah iare +nsti'asi em"un/

!e9es "erdarah Melena >"at 'en9ahar &aDement

Bisin/ usus : ..........................................................................................

N#eri te*an< l+*asi : ..........................................................................................

Ben+lan< l+*asi : ..........................................................................................

eluhan lainn#a :

...............................................................................................................................

...............................................................................................................................

...............................................................................................................................


...............................................................................................................................

...............................................................................................................................

C. TULANG 4 OTOT D INTEGUMEN $BONE( -

emam'uan 'er/era*an sendi Be"as er"atas

arese< l+*asi ..................................................................................................

aralise< l+*asi ................................................................................................

8emi'arese< l+*asi ..........................................................................................

re'itasi< l+*asi ..............................................................................................



Ben/*a*< l+*asi ...............................................................................................

e*a*uan< l+*asi .............................................................................................

!lasiditas< l+*asi .............................................................................................

S'astisitas< l+*asi ............................................................................................

*uran +t+t Simetris

7tr+'i

8i'ertr+'i

+ntra*tur

Mal'+sisi

i *e*uatan +t+t : =*strimitas atas.. =*strimitas "awah..

e;+rmitas tulan/< l+*asi.................................................................................

eradan/an< l+*asi...........................................................................................

erlu*aan< l+*asi..............................................................................................

atah tulan/< l+*asi..........................................................................................

ulan/ "ela*an/ N+rmal S*+li+sis

i;+sis &+rd+sis

10. KULIT4KULIT RAMBUT

iwa#at aler/i >"at.........................................................................

Ma*anan..................................................................

+sameti*...............................................................

&ainn#a....................................................................

Suhu *ulit 8an/at anas in/in

-arna *ulit N+rmal Sian+sis "iru I*teri**unin/

utih 'u9at C+*lat tuah#'er'i/mentasi

ur/+r Bai* Cu*u' uran/

e*stur 8alus asar

&esi : Ma9ula< l+*asi

ustula< l+*asi.........................................................

N+dula< l+*asi.........................................................

?esi*ula< l+*asi........................................................

a'ula< l+*asi..........................................................

l9us< l+*asi............................................................

%arin/an 'arut l+*asi..............................................................................................

e*stur ram"ut ...................................................................................................

istri"usi ram"ut...................................................................................................

Bentu* *u*u Simetris Irre/uler

Clu""in/ !in/er &ainn#a..................



...............................................................................................................................

...............................................................................................................................

11. SISTEM PENGIN,ERAAN -

a. Mataen/lihatan

!un/si 'en/lihatan : Ber*uran/ a"ur

anda Buta/ela'

era*an "+la mata : Ber/era* n+rmal iam

Ber/era* s'+ntannista/mus

?isus : Mata anan (?>) :............................................................

Mata *iri (?>S) :.............................................................

Selera

N+rmal'utih

unin/i*terus

Merahhi;ema+nun9tiDa Merah muda u9atanemi9

+rnea Benin/ eruh

7lat "antu a9amata &ensa *+nta* &ainn#a.

N#eri : .................................................................................................

eluhan lain :

". elin/a enden/aran :

!un/si 'enden/aran : Ber*uran/ Berden/un/ uli

9. 8idun/ en9iuman:

Bentu* : Simetris 7simetris

&esi

atensi

>"stru*si

N#eri te*an sinus

ransluminasi

CaDum Nasal -arna.. Inte/ritas..

Se'tum nasal eDiasi er;+rasi eradarahan

Se*resi< warna

+li' anan iri anan dan iri


...............................................................................................................................

...............................................................................................................................

1). LEHER ,AN KELENJAR LIM"E

Massa Ha ida*

%arin/an arut Ha ida*

elenar &im;e era"a ida* tera"a

elenar #r+id era"a ida* tera"a



1&. SISTEM REPRO,UKSI

a. Re7o/k3i P7ia

emerahan< &+*asi : ...................................................

atalG/atal< &+*asi : ....................................................

land enis : ...............................................................

Maetus retra : ............................................................

is9har/e< warna : .....................................................

Sr+tum : ..................................................................

8ernia : ..................................................................

elainan :

eluhan lain : .

a. Re7o/k3i +ani2a

emerahan< &+*asi : ...................................................

atalG/atal< &+*asi : ....................................................

erdarahan : ...............................................................

!l+ur 7l"us : ............................................................

Clit+ris : .....................................................................

&a"is : ..................................................................

retra : ..................................................................

e"ersihan : Bai* Cu*u' uran/

ehamilan :

a;siran 'artus :

eluhan lain.................................................................................................................................................................................................................................

a#udara :

Simetris 7simetris

Sear &esi

em"en/*a*an N#eri te*an

utin/ : Men+n+l atar &e9et Mastitis

-arna are+la .....................................................................................................

7SI &an9ar Sedi*it ida* *eluar

eluhan lainn#a.................................................................................................

...........................................................................................................................


..........................................................................................................................

,. POLA "UNGSI KESEHATAN

1 i h d h t d *it



...............................................................................................................................

...............................................................................................................................

...............................................................................................................................

2. Nutrisida Meta"+lisme

B : Cm

BB se*aran/ : /

BB Se"elum sa*it : /

iet :

Biasa Cair Sarin/ &una*

iet husus :

endah /aram endah *al+ri

endah &ema* endah urin &ainn#a.

Mual

Muntah.*alihari

esu*aran menelan Ha ida*

asa haus Ha ida*

eluhan lainn#a.....................................................................................................

Pola Makan Se9a7i49a7i Se3/a9 Saki2 Se8el Saki2

!re*uensihari+rsi

Na;su ma*an

%enis Ma*anan

%enis Minuman

%umlah minuman9924 am

e"iasaan ma*an

eluhanmasalah

Masalah e'erawatan

3. +la istirahat dan tidur

Masalah e'erawatan

4. +/niti; :



Masalah e'erawatan

5. +nse' diri (am"aran diri< ideal diri< identitas diri< har/a diri< 'eran ) :

Masalah e'erawatan

6. 7*tiDitas SehariGhari

Masalah e'erawatan

$. +'in/ +leransi terhada' Stress

Masalah e'erawatan

. NilaiG+la e#a*inan

Masalah e'erawatan

E. SOSIAL 4 SPIRITUAL

1. emam'uan "er*+muni*asi

2. Bahasa sehariGhari

3. 8u"un/an den/an *eluar/a :



4. 8u"un/an den/an teman'etu/as *esehatan+ran/ lain :

5. >ran/ "erartiterde*at :

6. e"iasaan men//una*an wa*tu luan/ :

$. e/iatan "eri"adah :

". ,ATA PENUNJANG $RA,IOLOGIS: LABORATORIUM: PENUNJANG

LAINNYA(

G. PENATALAKSANAAN ME,IS

. ....

Mahasiswa

( )



ANALISIS ,ATA

,ATA SUBYEKTI" ,AN

,ATA OBYEKTI"

KEMUNGKINAN

PENYEBABMASALAH

1. >: 30@ min< N: 100

@ min< the e@tended

e@'irati+n< "r+n9hial.

S: 9lient 9+m'lainin/ +;

sh+rtness +; "reath

narr+win/ +; the "r+n9hi Breath 'attern was n+t

e;;e9tiDe



PRIORITAS MASALAH

Ine;;e9tiDe "reathin/ 'attern ass+9iated with the narr+win/ +; the "r+n9hi



RENANA KEPERA+ATAN

Nama asien : Mr. %

uan/ awat :

,# Ke T;an $K7i2e7ia 9a3il( In2e7?en3i Ra3ional

1 7;ter the a9t +; nursin/ ;+r 3 @ 24 h+urs<

the 'atient is a"le t+:

1. es'irat+r# status: ?entilati+n

2. es'irat+r# status: 7irwa# 'aten9#

3. ?ital si/n Status

B# Criteria esults:

1. em+nstrate e;;e9tiDe 9+u/h and

"reath s+unds were 9lean< n+

9#an+sis and d#s'nea (9a'a"le +;

rem+Din/ s'utum< a"le t+ "reathe

easil#< n+ 'ursed li's)

2. Indi9ates a 'atent airwa# (the 9lient

d+es n+t ;eel su;;+9ated< the rh#thm

+; "reath< res'irat+r# ;reJuen9# in

the n+rmal ran/e< n+ a"n+rmal

"reath s+unds)

3. Si/ns ?ital si/ns within n+rmal

ran/e ("l++d 'ressure< 'ulse<

res'irati+n)

>'en the airwa#< use te9hniJues 9hin li;t +r aw

thrust i; ne9essar#

1. +siti+n the 'atient t+ ma@imiKe Dentilati+n

2. 7us9ultati+n +; "reath s+unds< n+te the

'resen9e +; additi+nal s+und

3. M+nit+r res'irati+n and >2 status

1. t+ hel' relieDe airwa#

2. t+ determine the additi+nal "reath

s+unds wheeKin/

3. t+ determine the res'irat+r# rate



IMPLEMENTASI ,AN E5ALUASI KEPERA+ATAN

Nama asien :

uan/ awat : Mr. %

,# KeIleen2a3i E?ala3i $SOAP(

T

6 1 1. +siti+nin/ the 'atient t+ ma@imiKe Dentilati+n

2. 7t the s+und +; "reath< n+te the 'resen9e +;

additi+nal s+und

3. M+nit+r res'irati+n and >2 status

S: he 'atient sa#s n+ l+n/er

"reathin/ ti/htness

>: atient &++*s ile@

7: Issues es+lDed

: InterDenti+n is st+''ed

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