IMPLEMENTASI DAN EVALUASI NO 2.docx

8/17/2019 IMPLEMENTASI DAN EVALUASI NO 2.docx

1/15

IMPLEMENTASI DAN

EVALUASI


2/15

CATATAN PERKEMBANGAN HARI -1 SHIFT SIANG

Nama Pasien : Tn “S” Jenis Kelamin : Laki-laki

Umur : 70 Taun N! " #M : $00%7&'7Tan((al : )- A*ril '0$+ D, Meis : $00%7&'7

N! D, .ak/u Im*lemen/asi Tan((al 1am E2aluasi Para3

' $)"00 $" Mem!ni/!r ukuran4 kesime/risan

an res*!n *u*il

#Pu*il: Is!k!r

#5: P!si/i3 kanan kiriUkuran *u*il ) mm

) A*ril '0$+'0"60

S: /iak a*a/ /erka1i

:

- 8a9insk ;e: ?00< 6)0- $07? @ - 6'? >>

- Diuresis: $'4% >>

- TD $&0$$0 mm(- T:6%4 '5

- I.L:6? >>

- .85: $))00 selul ara- P!sisi *asien men(aa* kekiri an semi 3!Bler

- Tin(ka/ kesaaran : 5!ma- C5S: E$M' V$

- Leuk!si/: $)4)00 selmm6- Se(menneu/r!3il %)40

A: masala 9elum /era/asi

1. Tissue perfusion

No Indikaor Pre Tu!uan Pos

1 Tekanan sis/!lik an

ias/!lik

" ) 6

# 9s/ruksi *em9ulu !/ak # ) '$ Kelainan *aa asil 5T-s>an - ) -

#. Neuro%o&i'a% saus

Jumaia

$+"00 '" M!ni/!r *eru9aan s/a/us (las(!B>!ma s>ale

#

Tin(ka/ kesaaran : 5!ma

C5S: E$M' V$

$+"00 $. Men>a/a/ res*!n *asien /eraa*

s/imulus an *eru9aan neur!l!(i

#- /am*ak menarik kaki saa/

ilakukan *emeriksaan 9a9insk

- /iak aa ke1an(

$+"00 ?" K!la9!rasi *em9erian /era*i

# Mani/!l $') ml

$7"60 (. Mem*!sisikan *asien *aa *!sisi

semi3!Bler # *!sisi kelien semi3!Bler

$%"60 ). Minimalkan s/imuli arilin(kun(an

#lin(kun(an /am*ak /enan( an 1umla *en(un1un( i9a/asi

$&"60 7" Mem!ni/!r /ekanan ara


3/15

#

TD: $&0$$0 mm(No Indikaor Pre Tu!uan Pos

$ Kesaaran 1 ) $

' Ke1an( ( ) )

6 Ukuran *u*il # ) '

P:

$" Minimalkan s/imulus lin(kun(an

'" M!ni/!r /in(ka/ kesaaran

6" M!ni/!r re3lek *u*il

?" Per/aankan *enan(an an( ase*/ik

)" K!la9!rasi *em9erian an/i9i!/ik

+" K!la9!rasi *em9erian 2as!ila/!r

'0"00 *. Mem!ni/!r in/ake an !u/*u/

>airan#

In/ake:

IVFD #L '0 /*m?00 ml

Die/ >air )0 >> < '0 >> air *u/i 1am

u/*u/:

Urine &00 >> + 1amI.L:$7) >>

8alan>e:7)0-$07? @ -6'? >>Diuresis: $'4% >>

'0"00 &" Mem!ni/!r suu an an(ka .85#

T:674%5

.85: $))00 selul ara

CATATAN PERKEMBANGAN HARI -1 SHIFT MA+AM


4/15

Nama Pasien : Tn “S” Jenis Kelamin : Laki-lakiUmur : 70 Taun N! " #M : $00%7&'7

Tan((al : )-+ A*ril '0$+ D, Meis : $00%7&'7


' '$"00 $" Mem!ni/!r ukuran4 kesime/risan an res*!n *u*il

#Pu*il: Is!k!r

#5: P!si/i3 kanan kiri

Ukuran *u*il ) mm

+ A*ril '0$+

0%"00


:

- 8a9insk ;e: &$+ - $)?7 @ - +6$ >>

- Diuresis: $74% >>- T:6%4 '5

- I.L:6? >>

- .85: $))00 selul ara- P!sisi *asien men(aa* kekiri an semi 3!Bler

- Tin(ka/ kesaaran : 5!ma

- C5S: E$M' V$- Leuk!si/: $)4)00 selmm6

- Se(menneu/r!3il %)40


1. Tissue perfusion



ias/!lik

" )

# 9s/ruksi *em9ulu !/ak # )

$ Kelainan *aa asil 5T-s>an - )

'$"00 '" M!ni/!r *eru9aan s/a/us (las(!B >!ma s>ale

#Tin(ka/ kesaaran : 5!ma

C5S: E$M' V$

'$"00 $. Men>a/a/ res*!n *asien /eraa* s/imulus an

*eru9aan neur!l!(i#

- /am*ak /an(an kanan klien (eme/ar

''"00 ?" K!la9!rasi *em9erian /era*i

# Mani/!l $') ml

''"00 (. Mem*er/aankan *!sisi *asien *aa *!sisi

semi3!Bler # *!sisi kelien semi3!Bler

''"00 ). Minimalkan s/imuli ari lin(kun(an

#lin(kun(an /am*ak /enan( an 1umla

*en(un1un( i9a/asi

''"60 7" K!la9!rasi *em9erian an/i9i!/ik #

>e3/ia,!ne $ (ram

''"60 %" K!la9!rasi *em9erian ak/i2a/!r >ere9ral#>i/>!line ', )00 m(


5/15



$ Kesaaran 1 )

' Ke1an( ( )

6 Ukuran *u*il # )

P:







0+"00 ,. Mem!ni/!r in/ake an !u/*u/ >airan

#

In/ake:IVFD #L '0 /*m 6)0 ml

IVFD Manni/!l $') ml5i/i>!line )00 m( ;? ml=

5e3/ia,!ne $ (ram i a*lus $0 mlDie/ >air )0 >> < '0 >> air *u/i 1amu/*u/:

Urine: $')0 >> '00>> ;'$"00=

)00 >> ;'?"00=

?00 >> ;06"00=$)0 >> ;0+"00=

$')0 >>I.L:66 >> 1am

8alan>e: &$+ - $)?7 @ - +6$ >>

Diuresis: $74% >>


6/15

CATATAN PERKEMBANGAN HARI -# SHIFT PAGI


Umur : 70 Taun N! " #M : $00%7&'7Tan((al : + A*ril '0$+ D, Meis : S/r!ke N!n-Gem!ra(ik


' $0"00 $" Mem!ni/!r ukuran4 kesime/risan an

res*!n *u*il

#Pu*il: Is!k!r

#5: kanan ;-= kiri ;>- .85: $))00 selul ara

- P!sisi *asien ke*ala i/n(aakan an semi 3!Bler

- Tin(ka/ kesaaran : 5!ma- C5S: E$M$ V$



1. Tissue perfusion



ias/!lik

$ ) ?

$0"00 '" M!ni/!r *eru9aan s/a/us (las(!B >!mas>ale

#


C5S: E$M$ V$$$"00 6" Men(e>ek (ula ara seBak/u

#

''0 m(l

0%"00 ?" Mem!ni/!r /ekanan ara#

$++%% mm( ;0%"00=

$0"00 )" Mem!ni/!r /ekanan ara

#

$70&6 mm(

$0"00 ). Men>a/a/ res*!n *asien /eraa*s/imulus an *eru9aan neur!l!(i

#

- 8a9insk ;


7/15

>i/>!line ', )00 m( # 9s/ruksi *em9ulu !/ak # ) 6

$ Kelainan *aa asil 5T-s>an - ) -



$ Kesaaran 1 ) $

' Ke1an( ( ) )

6 Ukuran *u*il 1 ) $

$0"00 &" K!la9!rasi *em9erian /era*i# Mani/!l $') ml

$$"00 1. Mem!ni/!r in/ake an !u/*u/ >airan#

In/ake:

IVFD #l '0 /*m )00 mlIVFD Manni/!l $') ml

5i/i>!line )00 m( ;? ml=5e3/ia,!ne $ (ram i a*lus $0 ml

Die/ >air )0 >> < '0 >> air *u/i 1amu/*u/:

Urine: ?00 >>

$00>> ;0&"00='00 >> ;$'"00=

$00 >> ;$?"00=I.L:66 >> 1am

8alan>e: 7&+- ?66 @ - 6+6 >>

Diuresis: $4$ >>


8/15

P:







$'"00 $$" Mem!ni/!r /ekanan ara

#

$+?%+ mm(


9/15

CATATAN PERKEMBANGAN HARI -# SHIFT MA+AM


Umur : 70 Taun N! " #M : $00%7&'7Tan((al : + H 7 A*ril '0$+ D, Meis : S/r!ke N!n-Gem!ra(ik


' '$"00 $" Mem!ni/!r ukuran4 kesime/risan anres*!n *u*il

#

Pu*il: Is!k!r #5: P!si/i3 kanan kiri

Ukuran *u*il ) mm

7 A*ril '0$+

0%"00


:

- 8a9insk ;e: &$+ - $)?7 @ - +6$ >>- Diuresis: $74% >>

- T:6%4 '5

- I.L:6? >>- .85: $))00 selul ara

- P!sisi *asien men(aa* kekiri an semi 3!Bler

- Tin(ka/ kesaaran : 5!ma- C5S: E$M' V$



$. Tissue perfusion



ias/!lik

" ) 6

# 9s/ruksi *em9ulu !/ak # ) '


". Neuro%o&i'a% saus

'$"00 '" M!ni/!r *eru9aan s/a/us (las(!B >!ma

s>ale#


C5S: E$M' V$

'$"00 $. Men>a/a/ res*!n *asien /eraa* s/imulusan *eru9aan neur!l!(i

#

- /am*ak /an(an kanan klien (eme/ar

''"00 ?" K!la9!rasi *em9erian /era*i# Mani/!l $') ml

''"00 (. Mem*er/aankan *!sisi *asien *aa *!sisisemi3!Bler

# *!sisi kelien semi3!Bler

''"00 ). Minimalkan s/imuli ari lin(kun(an


''"60 7" K!la9!rasi *em9erian an/i9i!/ik #

>e3/ia,!ne $ (ram

''"60 %" K!la9!rasi *em9erian ak/i2a/!r >ere9ral

#>i/>!line ', )00 m(


10/15


$ Kesaaran 1 ) $

' Ke1an( ( ) ?

6 Ukuran *u*il # ) '

P:







0+"00 ,. Mem!ni/!r in/ake an !u/*u/ >airan

#

In/ake:IVFD #L '0 /*m 6)0 ml

IVFD Manni/!l $') ml5i/i>!line )00 m( ;? ml=

5e3/ia,!ne $ (ram i a*lus $0 mlDie/ >air )0 >> < '0 >> air *u/i 1amu/*u/:

Urine: $')0 >> '00>> ;'$"00=

)00 >> ;'?"00=

600 >> ;06"00=$)0 >> ;0+"00=

$')0 >>I.L:66 >> 1am

8alan>e: &$+ - $6?7 @ - ?6$ >>

Diuresis: $74% >>


11/15

CATATAN PERKEMBANGAN HARI -$ SHIFT PAGI


Umur : 70 Taun N! " #M : $00%7&'7Tan((al : 7 A*ril '0$+ D, Meis : S/r!ke N!n-Gem!ra(ik


' 0%"00 $" Mem!ni/!r /ekanan ara#

$++%% mm(

7 A*ril '0$+

$?"00


:

- Tekanan ara:

$+?%+ mm(- CDS: ''0 m(l

- Pu*il: Is!k!r

- #5: kanan ;-= kiri ;>- Diuresis: $4$ >>

- T:6%4 '5- I.L:6? >>

- .85: $))00 selul ara- P!sisi *asien ke*ala i/n(aakan an semi 3!Bler

- Tin(ka/ kesaaran : 5!ma

- C5S: E$M$ V$

0&"00 $. Mem!ni/!r ukuran4 kesime/risan an

res*!n *u*il

#Pu*il: Is!k!r

#5: kanan ;-= kiri -=Ukuran *u*il ) mm

$0"00 ". Mem!ni/!r /ekanan ara#

$70&6 mm(

$0"00 (. M!ni/!r *eru9aan s/a/us (las(!B >!ma

s>ale#

Tin(ka/ kesaaran : 5!maC5S: E$M$ V$

$0"00 ). K!la9!rasi *em9erian /era*i# Mani/!l $') ml

$0"00 . Mem!ni/!r in/ake an !u/*u/ >airan#

In/ake:IVFD #l '0 /*m )00 ml

IVFD Manni/!l $') ml

5i/i>!line )00 m( ;? ml=5e3/ia,!ne $ (ram i a*lus $0 ml

Die/ >air )0 >> < '0 >> air *u/i 1amu/*u/:

Urine: ?00 >>

$00>> ;0&"00=


12/15

'00 >> ;$'"00=

$00 >> ;$?"00=

I.L:66 >> 1am8alan>e: 7&+- ?66 @ - 6+6 >>

Diuresis: $4$ >>

- Leuk!si/: $)4)00 selmm6

$0"00 *. Minimalkan s/imuli ari lin(kun(an


$0"00 ,. Men>a/a/ res*!n *asien /eraa*s/imulus an *eru9aan neur!l!(i

#- 8a9insk ;


13/15

- Se(menneu/r!3il %)40


1. Tissue perfusion



ias/!lik

$ ) ?

# 9s/ruksi *em9ulu !/ak # ) 6




$ Kesaaran 1 ) $

' Ke1an( ( ) )


P:








14/15

CATATAN PERKEMBANGAN HARI -$ SHIFT S/RE

Nama Pasien : Tn “S” Jenis Kelamin : Laki-lakiUmur : 70 Taun N! " #M : $00%7&'7

Tan((al : 7 A*ril '0$+ D, Meis : S/r!ke N!n-Gem!ra(ik


' $)"00 $" Mem!ni/!r 3rekuensi *erna3asanan sa/urasi !ksi(en

#

)$,meni/ &7

7 A*ril '0$+

$7"60


:

- Tekanan ara:

00 mm(- Pu*il: Is!k!r

- #5: kanan ;-= kiri ;-=

- Ukuran *u*il ) mm- Akral in(in


$. Tissue perfusion



ias/!lik

" ) $

# 9s/ruksi *em9ulu !/ak $ ) $


Paranse

$)"00 '" Men(auskul/asi suara na3as klien

#/iak aa r!n>i

$+"00 6" Mem!ni/!r 3rekuensi *erna3asanan sa/urasi !ksi(en

#?%,meni/ &?

$+"60 ?" Mem!ni/!r 3rekuensi *erna3asan

#Klien men(alami en/i na3as

$+"60 )" In/er2ensi ien/ikan an lakukan

resusi/asi#

#esusi/asi Jan/un( Paru ) siklus


15/15

". Neuro%o&i'a% saus


$ Kesaaran 1 ) $

' Ke1an( ( ) $


P: in/er2ensi ien/ikan

$+"60 +" Mem9erikan e*ine*rin ' am*ul

#

/iak aa nai

$7"00 7" Melakukan resusi/asi

#/iak aa na3as an enu/

1an/un( s*!n/an- klien ina/akan menin((al

IMPLEMENTASI DAN EVALUASI NO 2.docx

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Transcript of IMPLEMENTASI DAN EVALUASI NO 2.docx