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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
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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
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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 -
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Ma3ala9 Kee7a<a2an -
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%. 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
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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 :
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Masalah e'erawatan :
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*. ELIMINASI URI $BLA,,ER( -
r+du*si rine : .ml@hr
-arna :
Bau :
id * d l hl M t I * ti
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+liuri anas 8ematuri
#suri N+9turi
ateter C#st+st+mi
eluhan &ainn#a :
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Masalah e'erawatan :
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. 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 :
...............................................................................................................................
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Masalah e'erawatan :
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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 ..............................................................................................
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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..................
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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
Masalah e'erawatan :
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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
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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.................................................................................................
...........................................................................................................................
Masalah e'erawatan :
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,. POLA "UNGSI KESEHATAN
1 i h d h t d *it
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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; :
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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 :
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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
( )
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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
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PRIORITAS MASALAH
Ine;;e9tiDe "reathin/ 'attern ass+9iated with the narr+win/ +; the "r+n9hi
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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
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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