Tinjauan Kasus Keperawatan Gawat Darurat Presentasi Ckb

8/17/2019 Tinjauan Kasus Keperawatan Gawat Darurat Presentasi Ckb

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TINJAUAN KASUS KEPERAWATAN GAWAT DARURAT

A. PENGKAJIAN

Hari / Tanggal :Jumat 26 F!ruari 2"#6

Jam :#6."" WI$

Png%a&i :

#. I'ntita( Pa(in

Nama :N).*

U(ia :+, T-

Jni( Klamin :Prmuan

Pn'i'i%an :SD

Su%u $ang(a :Ja*a In'0n(ia

Agama :I(lam

Alamat :Panim!ang . 1imanggu

Diagn0(a 'i( : 10li3 A!'0mn

2. Png%a&ian Primr

Air*a)

Ti'a% a'a (um!atan &alan naa(na4a( (0ntanti'a% ((a%(uara na4a( &la(

Suara naa( 5a(i%ulr

$rat-ing

Naa( 3at trli-at ti'a% a'a nggunaan 0t0t !antu rnaa(anRR :26 / mnit

1ir3ulati0n

TD:#7"/8" mmHg

N: +7/ mnit


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RR:26/mnit

K0n&ungti5a ananmi(

A%ral 'ingin 1RT 9 , 'ti%

Di(a!ilit)

Ka'aan Umum lma- K(a'aran 30m0(mnti( G1S #; E7 6 Ri*a)at Pn)a%it Da-ulu

Kluarga %lin mngata%an %lin !lum rna- 'ira*aat 'iruma- (a%it

'.> Ri*a)at Pn)a%it Kluarga

%luarga %lin mngata%an 'i'alam %luargan)a ti'a% a'a )ang mmili%i ri*a)at

n)a%it )ag (riu( atauun mnular

.> Ri*a)at Alrgi


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Kluarga %lin mngata%an %lin ti'a% mmun)ai ri*a)at alrgi tr-a'a

ma%anan-*an atauun u'ara

,. Pmri%(aan Fi(i%

K(a'aran : 30m0(mnti( G1S:#; E7 6


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4. ?-r

Ti'a% a'a m!(aran %ln&ar t-)r0i'

g. Da'a

#.> Paru@Paru

I :r%m!angan 'a'a (imtri( ti'a% tr'aat nggunaan 0t0t !antu naa(

P :50%al 5rmitu(tra!a

P :%a%

A : 5(i%ulr

2>. Jantung

I : ti'a% tama% ul(a(i

P : i3tu( 30r'i( tra!a 'i I1 < mi'3la5i3ula

P :%a% ti'a% a'a m!(aran &antung

A : rgulr #2

-. A!'0mn

I :3m!ung

A : !i(ing u(u( 2" / mnit

P :t-)mani

P : ti'a% a'a n)ri t%an

i. Gntalia :

$r(i- ti'a% a'a &&a( Jni( %lamin la%i@la%i

J. E%(trmita(

#.> Ata( :

Ti'a% a'a &&a( tra(ang in4u( Na1l 2" tm a'a lngan %anan a%ral 'ingin

2.> $a*a- :

Ti'a% a'a u'ma a'a %(trmita( %a%i %anan %iria%ral 'ingin


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7. Pmri%(aan Pnun&ang

1% GDS -a(il: 272

;. Trai Tanggal 27 "2 2"#6

In4u( Na1l 2" tm

In&%(i raniti'in 2# amul

Pr0ralgr (u II %(tra >

$. ANA?ISA DATA

1. DIAGNBSA KEPERAWATAN

#. N)ri a%ut !r-u!ungan 'ngan Agn 3i'ra !i0l0gi(

TG?/JA Data F0%u( Eti0l0gi a(ala-

26 F!ruari 2""#6

#6.""

Jumat

D( :

%lin mngata%an

n)ri rut !agian

%anan (&a% 2

minggu )ang

lalu.n)ri tra(a

'itu(u% tu(u%tra(a

ana( 'an tru(

mnru((%ala

n)ri 6n)ri

'atang (aat

!rgra%

D0:

Klin tama%

mlin'ungi ara

n)ri

Klin tama%

gli(a-Klin tama%

mringi( %(a%itan

TD:#7"/8" mmHg

N:+7/mnit

RR:26/mnit

S:,6;"1

Agn 3i'ra

!i0l0gi(

N)ri a%ut


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D. INTER


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E. IP?EENTASI KEPERAWATAN

HARI/TG? JA DC IP?EENTASI RESPBN TTD

Jumat

26/"2/2"#6

#6."" I @la%u%an

ng%a&ian n)ri

(3ara %0mr-n(i4

trma(u% l0%a(i

%ara%tri(ti% 'ura(i

4r%un(i %ualita( 'an

4a%t0r r(iita(i

@mng0!(r5a(i ra%(i

n0n5r!al 'ari

%ti'a%n)amanan

@Guna%an t%ni%

%0muni%a(i trauti%

untu% mngta-ui

ngalaman n)ri

a(in

@mng5alua(i ngalaman n)ri

ma(a lamau

@mng%a&i ti 'an

(um!r n)ri untu% mnntu%an intr5n(i

(:

%lin %00rati4

0:

P:n)ri (aat

!rgra%

:n)ri (rti'itu(u% tu(u%

R:n)ri tru(

mnru( tra(a

ana(

S:(%ala n)ri 6

T:(tia ; mnit

(%ali

(: @

0: %lin

%00rati4

(: @

0: %lin

%00rati4

(: %lin

mngata%an ti'a%

rna- mra(%an

n)ri )g -!at

(lama ini

0: %lin tama%

mringi(%(a%ita

n

( :@0 :


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@mnga&ar%an tntang

t%ni% n0n

4arma%0l0gi

@mm!ri%an

analgti% untu%

mngurangi n)ri

@Ting%at%an i(tira-at

@K0la!0ra(i%an

'ngan '0%tr &i%a a'a

%lu-an 'an tin'a%an

n)ri ti'a% !r-a(il

n)ri r0((

im4lama(i

(:@

0:t%ni% na4a('alam

(:@

0: In&%(i

raniti'in 2#

amul

Pr0ralgr (u II

%(tra >

(:@

0:%lin

!ri(tira-at 'alam

0(i(i -a' u

(:@

0:%0la!0ra(i

'ngan '0%tr

'ilan&ut%an

F. E

'i!ri%an

A: n)ri a%ut !r-u!ungan 'ngan

agn 3i'r !i0l0gi( trata(i


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(!agian

P: lan&ut%an intr5n(i

air*a) anagmnt

m0nit0r %u 'an n)ri %0la!0ra(im'i(

RESUME KEPERAWATAN GAWAT DARURAT PADA Tn. S DENGAN KASUSDEMAM REMATIK DIRUANG IGD

RSUD. Prof. Dr. Margono Soekarjo Purwokerto

DISUSUN OLEH

ANIS LISTIANINGSIH

ATI SETIANINGSIH

A!I! WI NUGROHO

DESI ANISA URMALA " A#$%#$&%% '


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EKA NANDA MUR(IANTONO

SEKOLAH TINGGI ILMU KESEHATAN

MUHAMMADIAH GOM)ONG

*#$+

Tinjauan Kasus Keperawatan Gawat Darurat Presentasi Ckb

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