RENCANA PERAWATAN LULUK SH.docx

8/17/2019 RENCANA PERAWATAN LULUK SH.docx

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8. RENCANA TINDAKAN KEPERAWATAN BERDASAR NIC-NOC

N

O

DIAGNOSA KEPERAWATAN TUJUAN DAN KRITERIA HASIL INTERVENSI

1. Ketidakefektifan perfusi jaringan

otak

Denisi : Mengala! "en#$#nan

%!$&#la%!

Ja$!ngan '(a& )ang *a"a(

enggangg# &e%e+a(an.

Batasan Karakteristik :

- Ma%%a ($','"la%(!n "a$%!al

a,n'$al

- Ma%%a "$'($',!n a,n'$al Se&en en($!&el &!$! a&!ne(!&

- A(e$'%&le$'%!% a'$(!&

- D!%e&%! a$(e$!

- !,$!la%! a($!#

- M!&%'a a($!#

- T#'$ '(a&

- S(en'%!% &a$'(!*

- Ane#$!%a %e$e,$!

- K'ag#l'"a(! /!%al ane!a %el %a,!(0- Ka$*!'!'"a(! *!la(a%!

- K'ag#la%! !n($aa%&#la$ *!%e!na(a

- E,'l!%e

- T$a#a &e"ala

NOC :

- C!$1#la(!'n %(a(#%

Kriteria hasil :

Men*e'n%($a%!&an %(a(#%

%!$&#la%! )ang *!(an*a! *engan :

- Te&anan %)%('le *an *!a%('le

*ala

Ren(ang )ang *!+a$a"&an

/n'$al0

- T!*a& a*a '$(+'%(a(!& +!"'(en%!- T!*a& a*a (an*a-(an*a

"en!ng&a(an

Te&anan !n($a&$an!al

- P#"!l %e!,ang *an $ea&(!2

- T!ng&a( &e%a*a$an %'n'len

NIC :

Monitoring neurologis

3.M'n!('$ #&#$an4 &e%!e($!%an4

$ea&%! *an

Ben(#& "#"!l

5.M'n'('$ (!ng&a( &e%a*a$an &l!en

6.M'n!('$ (an*a-(an*a !(al

7.M'n!('$ &el#+an n)e$! &e"ala4

#al4

M#n(a+.

.M'n!('$ $e%"'n &l!en (e$+a*a" Peng',a(an.

9.H!n*a$! a&(!(a% ;!&a TIK

en!ng&a(

<.O,%e$a%! &'n*!%! %!& &l!en.

8.K'la,'$a%! "e,e$!an ',a(

ne#$'"$'(e&(!2

Terapi oksigen

3.Be$%!+&an ;alan na"a% *a$!%e&$e(

5.Pe$(a+an&an ;alan na"a% "a(en

6.Be$!&an '&%!gen %e%#a! !n($#&%!

7.M'n!('$ al!$an '&%!gen 4 &an#l



- O$('"nea

- Pen#$#nan ,#n)! na"a%

- Pe$#,a+an 2$e&>en%! na"a%

- "e$#,a+an "'la na"a%

- S!an'%!%- S"#(# *ala ;#la+ )ang

,e$le,!+an

- S#a$a na"a% (a,a+an

- Ta& a*a ,a(#&

'aktor $ang erhuungan :

L!ng&#ngan :

- Pe$'&'&

- Pe$'&'& "a%!2

- Te$"a;an a%a"

O,%($#&%! ;alan na"a% :

- A*an)a ;alan na"a% ,#a(an

- Ben*a a%!ng *ala ;alan na"a%

- E&%#*a( *ala ale'l!

- H!"e$"la%!a "a*a *!n*!ng ,$'n&#%

- M#&#% ,e$le,!+an

- Pen)a&!( "a$# ',%($#&%! &$'n!%

- Se&$e%! )ang $e$(a+an

- S"a%e ;alan na"a%

!%!'l'g!% :

- A%a

- Men#n;#&&an ;alan na"a% )ang

"a(en

/(!*a& e$a%a (e$1e&!&4 !$aa

na2a%4

$e&>en%! "e$na"a%an *ala$en(ang

N'$al4 (!*a& *a %#a$a na2a%

a,n'$al

engg#na&an na%al

Un(#& e2a%!l!(a%! %#1(!'n

na%'($a&eal

8.G#na&an ala( )ang %(e$!l %e(!a"

Mela&#&an (!n*a&an@. An;#$&an "a%!en #n(#& !%(!$a+a(

*an

Na"a% *ala %e(ela+ &a(e(e$

*!&el#a$&an

Da$! na%'($a&eal

3.M'n!('$ %(a(#% '&%!gen "a%!en

33.A;a$&a &el#a$ga ,aga!ana

ela&#&an

S#1(!'n

35.Hen(!&an %#1(!'n *an ,e$!&an

'&%!gen

A"a,!la "a%!en en#n;#&&an

,$a*!&a$*!4

Pen!ng&a(an %a(#$a%! O5 *ll

"ir#a$ Manaje(en

3.B#&a ;alan na2a%4 g#na&an

(e&n!& 1+!nl!2(

A(a# ;a> (+$#%( ,!la "e$l#

5.P'%!%!&an "a%!en #n(#&

ea&%!al&an

Ven(!la%!



- D!%2#ng%! ne#$'#%&#le$

- In2e&%!

- Jalan na"a% ale$g!&

6.I*en(!&a%! "a%!en "e$l#n)a

"ea%angan

Ala( ;alan na2a% ,#a(an

7.Pa%ang a)' ,!la "e$l#

.La&#&an %!'(e$a"! *a*a ;!&a"e$l#

9.Kel#a$&an %e&$e( *engan

,a(#&?%#1(!'n

<.A#%&#l(a%! %#a$a na2a%4 1a(a(

a*an)a

S#a$a (a,a+an

8.La&#&an %#1(!'n "a*a a)'

@.Be$!&an ,$'n&'*!la('$ ,!la "e$l#

3.Be$!&an "ele,a, #*a$a &a%a

,a%a+4

Na1l le,a,

33.A(#$ !n(a&e #n(#&

eng'"(!al&an

Ke%e!,angan 1a!$an

35.M'n!('$ $e%"!$a%! *an %(a(#% O5

)* Ketidakefektifan pola nafas

Denisi : In%"!$a%! *an ? a(a#

e&%"!$a%! )ang (!*a& e,e$!

en(!la%!

NOC

- Re%"!$a('$) %(a(#% : en(!la(!'n

- Re%"!$a('$) %(a(#% : A!$>a)

"a(en1)

- V!(al %!gn %(a(#%

NIC

"ir#a$ Manage(ent

3.B#&a ;alan na"a%4 g#na&an

(e&n!& 1+!nl!2(

A(a# ;a> (+$#%( ,!la "e$l#




- B$a*!"nea

- D!%"nea

- a%e e&%"!$a%! ean;ang- O$('"nea

- Pengg#naan '('( ,an(# "e$na2a%an

- Pengg#naan "'%!%! (!ga (!(!&

- Pen!ng&a(an *!ae(e$ an(e$!'$-

"'%(e$!'$

- Pen#$#nan (e&anan e&%"!$a%!

- Pen#$#nan (e&anan !n%"!$a%!- Pen#$#nan en(!la%! %een!(

- Pe$na"a%an ,!,!$

- Pe$na"a%an 1#'!ng +!*#ng

- Pe$#,a+an e&%&#$%! *a*a

- P'la na"a% a,n'$al /!$aa4

2$e&>en%!4

Ke*alaan

- Ta&!"nea

'aktor $ang erhuugan :

Kriteria !asil :

- Men*e'n%($a%!&an ,a(#&

e2e&(!2 *an S#a$a na"a% )ang ,e$%!+4 (!*a&

a*a

S!an'%!% *an *)%"ne# /a"#

Mengel#a$&an %"#(#4a"#

,e$na"a%

Dengan #*a+4 (!*a& a*a

"#$%e* l!"%0- Men#n;#&&an ;alan na"a% )ang

"a(en

/&l!en (!*a& e$a%a (e$1e&!&4

!$aa na2a%4

$e&>en%! "e$na"a%an *ala

$en(ang

N'$al4 (!*a& a*a %#a$a na"a%

A,n'$al0

- Tan*a-(an*a !(al *ala $en(ang

n'$al

5.P'%!%!&an "a%!en #n(#&

ea&%!al&an

Ven(!la%!

6.I*en(!&a%! "a%!en "e$l#)a"ea%angan

Ala( ;alan na"a% ,#a(an

7.Pa%ang a)' ,!la "e$l#

.La&#&an %!'(e$a"! *a*a ,!la

"e$l#

9.Kel#a$&an %e&$e( *engan ,a(#&

a(a# S#1(!'n

<.A#%&#l(a%! %#a$a na"a%4 1a(a(

a*an)a

S#a$a (a,a+an

8.La&#&an %#1(!'n "a*a a)'

@.Be$!&an ,$'n1+'*!la('$ ,!la "e$l#

3.Be$!&an "ele,a, #*a$a &a%%a

,a%a+

Na1l ,a%a+

33.A(#$ !n(a&e 1a!$an #n(#&



- An%!e(a%

- Ce*e$a e*#la %"!nal!%

- De2'$!(a% *!n*!ng *a*a

- D!%2#ng%! ne#$'#%&#le$- Gangg#an #%&#l'%&ele(al

- Gangg#an ne#$'l'g!% / EEG "'%!(!24

($a#a

Ke"ala4 gangg#an &e;ang 0

- H!"e$en(!la%!

- Ia(#$!(a% ne#$'l'g!%

- Kele(!+an

- Kele(!+an '('( "e$na"a%an

- N)e$!

- O,e%!(a%

- P'%!%! (#,#+ )ang eng+a,a(

e&%"an%! "a$#

- S!n*$' +!"'en(!la%!

/ (e&anan *a$a+4 na*!4

"e$na"a%an0

eng'"(!al

Kan &e%e!,angan 1a!$an

35.M'n!('$ $e%"!$a%! *an %(a(#% O5

Oksigen Therap$

3.Be$%!+&an #l#(4 +!*#ng *an

%e&$e(

T$a&ea

5.Pe$(a+an&an ;alan na"a% )ang

"a(en

6.A(#$ "e$ala(an '&%!gena%!

7. M'n!('$ al!$an '&%!gen

.O,%e$a%! a*an)a (an*a-(an*a

H!"'en(!la%!

9.M'n!('$ a*an)a &e1ea%an

"a%!en

Te$+a*a"'&%!gena%!

+ital sign (onitoring

3.M'n!('$ TD4 na*!4 %#+#n*an RR

5.Ca(a( a*an)a #&(#a%! (e&anan



*a$a+

6.M'n!('$ VS %aa( "a%!en

,e$,a$!ng4 *#*#&

A(a# ,e$*!$!7.A#%&#l(a%! TD "a*a &e*#a

lengan *an

Ban*!ng&an

.M'n!('$ TD4 na*!4 RR4 %e,el#4

%elaa4

Dan%e(ela+ a&(!(a%

9.M'n!('$ &#al!(a% *a$! na*!

<.M'n!('$ 2$e&>en%! *an !$aa

"e$na"a%an

8.M'n!('$ %#a$a "a$#

@.M'n!('$ "'la "e$na"a%an

a,n'$al

3. M'n!('$ %#+#4 >a$na4 *an

&ele,a,an

K#l!(

<.M'n!('$ %!an'%!% "e$!2e$

8.M'n!('$ a*an)a 1#%+!ng ($!a*



/(e&anan

Na*! )ang ele,a$4 ,$a*!&a$*!4

Pen!ng&a(an %!%('l!&0

@.I*en(!&a%! "en)e,a, *a$!"e$#,a+an

V!(al %!gn,* Ketidaksei(angan nutrisi

kurang dari

Keutuhan tuuh

Denisi : A%#"an n#($!%! (!*a& 1#&#"

#n(#&

Meen#+! &e,#(#+an e(a,'l!&


- Be$a( ,a*an 5 a(a# le,!+

*!,a>a+ $en(ang

Be$a( ,a*an !*eal

- B!%!ng #%#% +!"e$a&(!2

- Ce"a( &en)ang %e(ela+ a&an

- D!a$e

- Gangg#an %en%a%! $a%a

- Ke+!langan $a,#( ,e$le,!+an

NOC

- N#($!(!'nal %(a(#% : ''* an* #!*

!n(a&e

- N#($!(!'n %(a(#% : n#($!en( !n(a&e

- We!g+( 1'n($'l

Kriteria !asil:

- A*an)a "en!ng&a(an ,e$a(

,a*an %e%#a!

Dengan (#;#an

- Be$a( ,a*an !*eal %e%#a! (!ngg!

,a*an

- Ma"# eng!*en(!&a%!

&e,#(#+an

N#($!%!

- T!*a& a*a (an*a aln#($!%!

NIC

Nutrition Manage(ent

3.Ka;! a*an)a ale$g! a&anan

5.K'la,'$a%! *engan a+l! g!=!

#n(#&

Menen(#&an ;#la+ &al'$! *an

n#($!%!

ang e,#(#+&an "a%!en

6.An;#$&an "a%!en #n(#&

en!ng&a(&an

In(a&e 2e

7.An;#$&an "a%!en #n(#&

en!ng&a(&an

P$'(e!n *an !( 1

.Be$!&an %#,%(an%! g#la

9.a&!n&an *!!( )ang *!a&an



- Kelea+an '('( "eng#n)a+

- Kelea+an '('( #n(#& enelan

- Ke$a"#+an &a"!le$

- Ke%ala+an !n2'$a%!- Ke%ala+an "e$%e"%!

- Ke(!*a&a"#an ea&an

a&anan

- K$a a,*'en

- K#$ang !n2'$a%!

- K#$ang !na( "a*a a&anan

- Me,$an #&'%a "#1a(

- N)e$! a,*'en

- Pen#$#nan ,e$a( ,a*an *engan

a%#"an

Ma&anan a*e&#a(

- Sa$!a>an $'ngga #l#(

- T'n#% '('( en#$#n

- Men#n;#&&an "en!ng&a(an 2#ng%!

Penge1a"an *a$! enelan

- T!*a& (e$;a*! "en#$#nan ,e$a(

,a*an ang ,e$a$(!

engan*#ng

T!ngg! %e$a( #n(#& en1ega+

&'n%(!"a%!

<.Be$!&an a&anan )ang (e$"!l!+8.A;a$&an "a%!en ,aga!ana

e,#a(

Ca(a(an a&anan +a$!an

@.M'n!('$ ;#la+ n#($!%! *an

&an*#ngan

Kal'$!

3.Be$!&an !n2'$a%! (en(ang

&e,#(#+an

N#($!%!

@.Ka;! &ea"#an "a%!en #n(#&

en*a"a(

Kan n#($!%! )ang *!,#(#+&an

Nutrition Monitoring

3.BB "a%!en *ala ,a(a% n'$al

5.M'n!('$ a*an)a "en#$#nan ,e$a(

,a*an

6.M'n!('$ (!"e *an ;#la+ a&(!!(a%



)ang

B!a%a *!la&#&an

7.M'n!('$ l!ng&#ngan %elaa

a&an

.Ja*>al&an "eng',a(an *an

(!n*a&an

T!*a& %elaa ;a a&an

9.M'n!('$ &#l!( &e$!ng *an

"e$#,a+an

P!gen(a%!

<. 'n!('$ (#$g'$ &#l!(

8.M'n!('$ &e&e$!ngan4 $a,#(

&#%a *an

M#*a+ "a(a+

@. M'n!('$ #al *an #n(a+

3.M'n!('$ &a*a$ al,#!n4 ('(al

"$'(e!n4

HB DAN +(

33.M'n!('$ "#1a(4 &ee$a+an4 *an

Ke&e$!ngan ;a$!ngan &'n;#ng(!a

35.M'n!('$ &al'$! *an !n(a&e n#($!%!



36. Ca(a( a*an)a e*ea4

+!"e$e!&4

H!"e$('n!& "a"!la l!*a+ *an

1a!(a% '$al

37.Ca(a( ;!&a l!*a+ ,e$>a$na

agen(a4

%1a$le(

-* !a(atan (oilitas sik

Denisi : Ke(e$,a(a%an *ala

ge$a&an %!&

A(a# %a(# a(a# le,!+ e&%($e!(a%

%e1a$a an*!$! *an (e$a$a+

Batasan karakteristik :

- D!%"nea %e(ela+ ,e$a&(!!(a%

- Gangg#an %!&a" ,e$;alan

- Ge$a&an la,a(

- Ge$a&an %"a%(!&

- Ge$a&an (!*a& (e$&''$*!na%!

- In%(a,!l!(a% "'%(#$

- Ke%#l!(an e,'la&-,al!& "'%!%!

NOC

- J'!n( 'een( : a&(!e

- M',!l!() leel

- Sel2 1a$e : ADL%

- T$an%2e$ "e$2'$an1e

Kriteria !asil :

- Kl!en en!ng&a( *ala a&(!!(a%

%!&

- Menge$(! (#;#an *a$!

"en!ng&a(an

M',!l!(a%

- Mee$,al!%a%!&an "e$a%aan

*ala

NIC

./er&ise Therapi : a(ulation

3.M'n!('$!ng !(al %!gn %e,el#

*an

Se%#*a+ la(!+an *an l!+a( $e%"'n

"a%!en

Saa( la(!+an

5.K'n%#l(a%!&an *engan (+e$a")

%!&

Ten(ang $en1ana a,#la%!

%e%#a! *engan

Ke,#(#+an

6.Ban(# &l!en #n(#& engg#na&an

('ng&a(



- Ke(e$la,a(an $en(ang ge$a&

- Ke(!*a&n)aanan

- Mela&#&an a&(!!(a% la!n %e,aga!

"enggan(!

Pe$ge$a&an / !%al en!ng&a(&an

"e$+a(!an

Pa*a a&(!!(a% '$ang la!n4

engen*al!&an

Pe$!la&#4 2'&#% "a*a a&(!!(a%

%e,el# %a&!(

- Pen#$#nan lea"#an ela&#&an

Ke($a"!lan '('$!& +al#%

- Pen#$#nan &ea"#an ela&#&an

Ke($a"!lan '('$!& &a%a$

- Pen#$#nan >a&(# $ea&%!

- T$e'$ a&!,a( ,e$ge$a&

Pen!ng&a(an &e&#a(an *an

&ea"#an

Be$"!n*a+

- Me"e$aga&an "engg#naan ala(

,an(#

Un(#& ',!l!%a%! />al&e$0

Saa( ,e$;alan4 *an 1ega+

(e$+a*a"

Ce*e$a

7.A;a$&an "a%!en a(a# (enaga

&e%e+a(an

La!n (en(ang (e&n!& a,#la%!

.Ka;! &ea"#an "a%!en *ala

a,#la%!

9.Ka;! &ea"#an "a%!en *ala

',!l!%a%!

<.La(!+ "a%!en *ala "een#+an

Ke,#(#+an ADL% %e1a$a an*!$!

%e%#a!

Kea"#an

8.Da"!ng! *an ,an(# "a%!en %aa(

M',!l!%a%! *an ,an(# "en#+!

&e,#(#+an

ADLS "a%!en

@.Be$!&an ala( ,an(# ;!&a "a%!en

ee$l#&an

3.A;a$&an "a%!en ,aga!ana



e$#,a+

P'%!%! *an ,e$!&an ,an(#an ;!&a

J!&a *!"e$l#&an0* !a(atan Ko(unikasi eral

Denisi: "en#$#nan4 "ela,a(an4a(a# &e(!*a&a"#an

#n(#&ene$!a4 e"$'%e%4

eng!$!4 *an? a(a# engg#na&an

%!%(e %!,'l

Batasan Karakteristk :

- De%!( "engl!+a(an ('(al

- De%!( !%#al "a$%!al

- D!%'$!en(a%! '$ang- D!%'$!en(a%! $#a+

- D!%'$!en(a%! >a&(#

- D!%"nea

- Gaga"

- Ke%#l!(an *ala &e+a*!$an (e$(en(#

- Ke%#l!(an ea+a! &'#n!&a%!

- Ke%#l!(an e"e$(a+an&an

&'#n!&a%!

- Ke%#l!(an enge&%"$e%!&an "!&!$an%e1a$a

Ve$,al /!%al a2a%!a4 *!%2a%!a4

a"$a&%!a4

D!%le&%!a0

NOC

- an)e(! %el2 1'n($'l-1'"!ng

- Sen%'$)?2#n1('n : +ea$!ng an*

!%!'n

- 2ea$ %el+ &'n($'l

Kriteria !asil :

- K'#n!&a%! : "ene$!aan4

!n(e$"$e(a%!4

Dan e&%"$e%! "e%an l!%an4 (#l!%an*an

n'n e$,al en!ng&a(

- K'#n!&a%! e&%"$e%!2/&e%#l!(an

,!1a$a0 :

E&%"$e%! "e%an e$,al *an?a(a#

n'n

Ve$,al )ang ,e$a&na

- K'#n!&a%! $e%e"(!2 /&e%#l!(an

Men*enga$0 : "ene$!aan&'#n!&a%!

Dan !n(e$"$e(a%! "e%an e$,al

*an?a(a#

N'n e$,al

NIC

Co((uni&ation .n&han&e(ent: spee&h

De&it

3.G#na&an "ene$;ea+ ;!&a

*!"e$l#&an

5.Be$! %a(# &al!a( %!"le ,!la

,e$(e#4

J!&a *!"e$l#&an

6.K'n%#l(a%!&an *engan *'&(e$

&e,#(#+an Te$a"! >!1a$a

7.D'$'ng "a%!en #n(#&

,e$&'#n!&a%!

Se1a$a "e$la+an *an #n(#&

eng#lang!

Pe$!n(aan

.Denga$&an *engan "en#+

"e$+a(!an

9.Be$*!$! *!*e"an "a%!en &e(!&a,e$,!1a$a

<.A;a$&an ,!1a$a *engan e%'2ag#%

;!&a

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