8/18/2019 Asuhan Keperawtan Pada Pasien Pada Tn (Repaired)
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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%*
8/18/2019 Asuhan Keperawtan Pada Pasien Pada Tn (Repaired)
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8/18/2019 Asuhan Keperawtan Pada Pasien Pada Tn (Repaired)
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+. 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&
8/18/2019 Asuhan Keperawtan Pada Pasien Pada Tn (Repaired)
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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$'it
Resi1o ter%2i
8e&2%r%5%&
8/18/2019 Asuhan Keperawtan Pada Pasien Pada Tn (Repaired)
5/11
*e&g%&2$&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%&
8/18/2019 Asuhan Keperawtan Pada Pasien Pada Tn (Repaired)
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)
8/18/2019 Asuhan Keperawtan Pada Pasien Pada Tn (Repaired)
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$2%5
ter%2i&7%
8er2%r%5%&4*o&itor &i'%i
8/18/2019 Asuhan Keperawtan Pada Pasien Pada Tn (Repaired)
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4tr%$*%
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
8/18/2019 Asuhan Keperawtan Pada Pasien Pada Tn (Repaired)
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 &$trisi
4-er1%'%-or%si 2e&g%& 2o1ter 2%'%* 8e*-eri%&
t5er%8i
8/18/2019 Asuhan Keperawtan Pada Pasien Pada Tn (Repaired)
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VI. EVALUASI
N%*% T&. B
R$%&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
8/18/2019 Asuhan Keperawtan Pada Pasien Pada Tn (Repaired)
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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%&
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