368214856-pengkajian-adhf.doc

JURUSAN JURUSA N KEPERAWA KE PERAWATAN  TAN  FAKULTAS KEDOKTERAN  UNIVERSITAS BRAWIJAYA

PENGKAJIAN DASAR KEPERAWATAN Nama Mahasiswa

: Angga Dwi Saputra

Tempat Praktik

: Ruang 27

NIM

: 135070200111005

Tg! Praktik

: 13"1# agustus 2017

A. Identitas Identitas Klien Klien Nama

:Tn! M!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! N$! RM

:1070%%%%

&sia

:'2 tahun

:10 Agustus 2017

(enis ke keamin

:Pria!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!! Tg! Pe Pengka)ian

 Aamat

:Sing$sari* Maang!!!!!!!!!!!! Maang!!!!!!!!!!!! !! Sum+er in,$rmasi in,$rmasi :-ien .an -euarga -euarga

N$! te teep$n

: titi.ak te terka)i!!!!!!!!! !!!!!!!!! !!!!!!!! !!!!!! Nama k kg! .e .ekat /g /g +i +isa .i .ihu+ungi:Tn! I

Sta Status tus pern pernik ikah ahan an

:men :menik ikah ah!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!!! !!!!! !!

 Agama

:isam!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!! !!!!!!! !!!!!!! Status

:Anak

Suku

:(awa!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! Aamat

:Sing$sari* Maang

Pen.i.ikan

:SD!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! N$! teep$n

:ti.ak terka)i

Peker)aan

:Swasta!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! Pen.i.ikan

: titi.ak te terka)i

ama +erker)a

: ti.ak terka)i!!!!!!!!!!!!!!!!!!!!!!! Peker)aan

: ti.ak terka)i

Tg! Masuk

:15 Agustus 2017

B. Status Status kesehatan kesehatan Saat Saat Ini 1! -euhan utama

: pasien mengeuh sesak .an .a.an/a terasa sakit

2! ama keuhan

: se)ak tiga +uan /ang au sakit se)ak masuk RS

3! -ua -uait itas as keu keuha han n

: kua kuait itas as se.i se.iki kitt n/e n/eri ri** n/e n/eri ri teka tekan n * .an .an ter teras asa a tum tumpu pu .i .i .a. .a.a a kiri kiri .an .an

men/e+ar  ! akt$r penetus

: gaga )antung

5! akt$r pem+erat

: .igerakkan

'! &pa/a /g! teah .iakukan 7! Diagn$sa me.is

: .i+aw ke RS

:

a!

AD4 AD4!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!!! !!!!! !!!!! !!!!! !!!!! !!!!! Tangg angga a 10 Agus Agustu tus s 2017 2017

+!

!!!! !!!!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !!!! !! Tangg angga a

!

!!!!! !!!!!!!! !!!!!! !!!!!! !!!!!! !!!!! !!!!! !!!!!! !!!!!! !!!!!! !!!!! !!!!! !!!!!! !!!!!! !!!!!! !!!!! !!!!! !!!!!! !!!!!! !!!!!! !!!!! !!!!! !!!!!! !!!!!! !!!!!! !!!!! !!!!! !!!!!! !!!!!! !!! Tangg angga a!!! !!!!!! !!!!!! !!!!! !!!!! !!!!!!! !!!!!!! !!!!!!! !!!!!!!! !!!!!!! !!!!!!! !!!!!!! !!!

C. Riwayat Riwayat Kesehat Kesehatan an Saat Ini Pasien +a.an terasa emas* .a.a terasa sesak* .an t erasa sakit! Pasien masuk ewat ID RSSA! -e.aan umum pasien emah* 6S 5'* na,as muai sesak se)ak 1 +uan /ang au!muai mua .an sesak se)ak 1 minggu /ang au! -aki .an tangan +engkak ketika masuk RS* pasien .i$nis sakit  )antung 1 +uan +uan /ang au .an .an ti.ak patuh minum minum $+at )antung! )antung! D. Riwayat Kesehatan Terdahulu 1! Pen/akit Pen/akit /g /g pernah pernah .ia .iaami: ami: a! -eeakaan 8)enis 9 waktu

:ti.ak a.a

+! ;perasi 8)enis 9 waktu

:pemasangan ring )antung 1 +uan /ang au

! Pen/akit: -r$nis

:hipertensi* gaga )antung!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

 Akut

:ti.ak a.a!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!





.! Terakhir masuki RS

:3 +uan /ang au

e! 2! Aergi 8$+at* makanan* pester* .: Tipe Reaksi Ti.ak a.a aergi!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Tin.akan

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 3! Imunisasi: 8  <6 8  P$i$ 8  DPT

8  4epatitis 8  6ampak 8  !!!!!!!!!!!!!!!!!

! -e+iasaan: (enis Mer$k$k

rekuensi (umah aman/a setiap hari!!!!!!!!!!!!!!!!!! 1 +ungkus!!!!!!!!!!!!!!!!!!!!!!!! +erhenti 3 +uan au

-$pi

2 kai sehari!!!!!!!!!!!!!!! 1 angkir!!!!!!!!!!!!!!!!!!!!!!!!!!

 Ak$h$

ti.ak terka)i!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

5! ;+at"$+atan /g .igunakan: (enis aman/a ;+at )antung!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

D$sis

E. Riwayat Keluara  A/ah .ari pasien pernah mengaami hipertensi .an i+u .ari pasien mempun/ai riwa/at DM =N;RAM x

x

4t

x

x

x

x

x

x

x

x

x

x

> aki"aki > Perempuan %

> Meningga > Pasien

!. Riwayat "inkunan (enis -e+ersihan 




Rumah +ersih!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! +ersih ti.ak a.a!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! ti.ak a.a

Peker)aan



P$usi

ti.ak a.a!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! ti.ak a.a



?entiasi

ukup!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! ukup



Penaha/aan

ukup!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! ukup

G. P#la Akti$itas%"atihan 

Makan@minum

Rumah 0!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 0

Rumah Sakit



Man.i

0!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 2




0!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 2!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!



T$ieting

0!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 2!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!



M$+iitas .i tempat ti.ur

0!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 0!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!




0!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 2!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!




0!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!



Naik tangga

0!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Pemberian Skor: 0 = mandiri, 1 = alat bantu, 2 = dibantu orang lain, 3 = dibantu orang lain, 4 = tidak mampu

&. P#la Nutrisi 'eta(#lik 

(enis .iit@makanan

Rumah Rumah Sakit nasi* sa/ur* auk ren.ah garam!! .iet )antung II



rekuensi@p$a

3 sehari!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 3 sehari



P$rsi /g .iha+iskan

1 piring!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!



-$mp$sisi menu

nasi sa/ur auk!!!!!!!!!!!!!!!!!!!!!! nasi sa/ur auk



Pantangan

tinggi garam!!!!!!!!!!!!!!!!!!!!!!!!!! tinggi garam .an pa.at



Napsu makan

n$rma!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! ter.apat penurunan



uktuasi << ' +n! terakhir

$erhigh!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! ter.apat penam+ahan



(enis minuman

air putih!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! air putih



rekuensi@p$a minum

sering!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! )arang



eas /g .iha+iskan

# geas!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!  geas



Sukar menean 8pa.at@air

agak suit menean!!!!!!!!!!!!!!!! agak suit menean pa.at



Pemakaian gigi pasu 8area

ti.ak a.a!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! ti.ak a.a



Riw! masaah pen/em+uhan uka ti.ak a.a!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! ti.ak a.a

1500 kka@hari

I. P#la Eli)inasi Rumah 

Rumah Sakit


- rekuensi@p$a

1 sehari tiapa pagi!!!!!!!!!!!!!!!!!!!!! ti.ak tentu

- -$nsistensi

pa.at!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! air@unak

- Barna 9 +au

ke$katan* khas!!!!!!!!!!!!!!!!!!!!!!!!! ke$katan* khas

- -esuitan

ti.ak a.a!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! ke t$iet

- &pa/a mengatasi

ti.ak a.a!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! pakai p$p$k .ewasa




- rekuensi@p$a

10  sehari!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! ti.ak tentu

- -$nsistensi

air!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! air  

- Barna 9 +au

kekuningan* +au khas!!!!!!!!!!!!!!!!! kuning )ernih* khas

- -esuitan

ti.ak a.a!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! ke t$iet

- &pa/a mengatasi

ti.ak a.a!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! pakai urina

J. P#la Tidur%Istirahat 

Ti.ur siang:aman/a

Rumah Rumah Sakit 1 )am !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! C )am

- (am 2 s@. 3

1!00"15!00 !!!!!!!!!!!!!!!!!!!!!!!!!

1!30"1'!00!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

- -en/amanan sth! ti.ur

n/aman !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

n/aman!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

- Ti.ur maam: aman/a

7*5 )am !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! ' )am

- (am 21!00 s@. 0!30

21!00"0!30 !!!!!!!!!!!!!!!!!!!!!!!!! 22!00"05!00

- -en/amanan sth! ti.ur

n/aman !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

ti.ak terka)i!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

- -e+iasaan s+m! ti.ur

ti.ak a.a !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

ti.ak a.a!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

- -esuitan

ti.ak a.a !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

suit mengawai ti.ur!!!!!!!!!!!!!!!!!!

- &pa/a mengatasi

ti.ak a.a !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

ti.ak a.a upa/a untuk mengatasi

K. P#la Ke(ersihan Diri Man.i:rekuensi

Rumah Rumah Sakit 2 sehari !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 1 sehari

- Penggunaan sa+un

man.iri !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

-eramas: rekuensi

2 hari sekai !!!!!!!!!!!!!!!!!!!!!!!!!!!!! 2 hari ti.ak sama sekai

- Penggunaan shamp$$

sering !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

$s$s$k gigi: rekuensi

2 sehari !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 2 sehari

- Penggunaan $.$

seau tiap man.i !!!!!!!!!!!!!!!!!!!!



anti +a)u:rekuensi

2 sehari !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 1 sehari



Mem$t$ng kuku: rekuensi

1 minggu sekai !!!!!!!!!!!!!!!!!!!!!!! ti.ak pernah



-esuitan

ti.ak mengaami kesuitan !!!!!!! kesuitan man.i aki+at sakit



&pa/a /g .iakukan

ti.ak a.a !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! .iseka







.iseka

ti.ak pernah

2 sehari

". P#la T#leransi%K#*in Stres 1! Pengam+ian keputusan:

8  sen.iri

8  .i+antu $rang ain* se+utkan*istri* .an anak

2! Masaah utama terkait .engan perawatan .i RS atau pen/akit 8+ia/a* perawatan .iri* .:!!!!!!!!!!!!!!! 3! ang +iasa .iakukan apa+ia stress@mengaami masaah: +ererita .engan istri ! 4arapan seteah men)aani perawatan: .apat segera puang 5! Peru+ahan /ang .irasa seteah sakit: kesuitan meakukan akti,itas '. K#nse* Diri

1! am+aran .iri: kepaa rumah tangga .engan 2 $rang anak 2! I.ea .iri: pasien mengetahui +ahwa .irin/a sakit 3! 4arga .iri: pasien menerima pen/akitn/a ! Peran: ti.ak a.a masaah 5! I.entitas .iri a/ah se+agai $rang tua .ari 2 $rang anakn/a N. P#la Peran + &u(unan 1! Peran .aam keuarga suami .an a/ah .ari 2 $rang anakn/a 2! Sistem pen.ukung:@istri@ .an anak@tetangga@[email protected]@ti.ak a.a@ain"ain* se+utkan:!!!!!!!!!!!!!! 3! -esuitan .aam keuarga:

8  4u+! .engan $rang tua

8  4u+!.engan pasangan

8  4u+! .engan sanak sau.ara 8  4u+!.engan anak 8  ain"ain se+utkan* ti.ak a.a ! Masaah tentang peran@hu+ungan .engan keuarga seama perawatan .i RS: ti.ak a.a 5! &pa/a /g .iakukan untuk mengatasi: ti.ak a.a

,. P#la K#)unikasi 1!
8

 

N$rma

8 
8  Ti.ak )eas

8 
8 
8  Rentang perhatian:!!!!!!!!!!!!!!!!!!!!!!!!!!!!

8  Mampu mengerti pem+iaraan $rang ain8  A,ek:!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 8 Sen.iri

2! Tempat tingga: 8

 -$s@asrama

8


3! -ehi.upan keuarga a! A.at istia.at /g .ianut: a.at )awa +! Pantangan 9 agama /g .ianut: ti.ak a.a ! Penghasian keuarga:

8  E Rp! 250!000 8  Rp! 250!000 F 500!000 8  Rp! 500!000 F 1 )uta

8  Rp! 1 )uta F 1!5 )uta 8  Rp! 1!5 )uta F 2 )uta 8  G 2 )uta

P. P#la Seksualitas 1! Masaah .aam hu+ungan seksua seama sakit: 8  ti.ak a.a

8   a.a

2! &pa/a /ang .iakukan pasangan: 8  perhatian

8  sentuhan

8  ain"ain* seperti* ti.ak terka)i

-. P#la Nilai + Ke*erayaan 1! Apakah Tuhan* agama* kepera/aan penting untuk An.a* a 2! -egiatan agama@kepera/aan /g .iakukan .irumah 8)enis 9 ,rekuensi: sh$at 5 waktu

3! -egiatan agama@kepera/aan ti.ak .apat .iakukan .i RS: +er.$a ! 4arapan kien terha.ap perawat untuk meaksanakan i+a.ahn/a: ti.ak terka)i

R. Pe)eriksaan !isik 1! -ea.aan &mum: ukup +aik 



-esa.aran:$mp$s mentis 86S:  5 ' Tan.a"tan.a ita: " Tekanan .arah : 110@H0 mm4g " Na.i #2@menit



Tinggi +a.an: 1'5 m!!!!!!!




" Suhu : 3' $6 " RR

: 21 @menit

2! -epaa 9 eher  a! -epaa: Perse+aran ram+ut kepaa n$rma* ti.ak a.a esi* ti.ak a.a massa* ram+ut +ersih* kuit kepaa +ersih* .istri+usi ram+ut merata wa)ah kien grimae!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! +! Mata: Ti.ak a.a gangguan pengihatan* ti.ak a.a esi* k$n)ungtia ti.ak anemis* mata simetris* sera ti.ak ikterik ! 4i.ung: Ti.ak a.a sekret* ti.ak a.a esi* u+ang hi.ung simetris* ti.ak a.a sum+atan* ti.ak a.a per.arahan .! Muut 9 tengg$r$kan: igi n$rma* muk$sa +i+ir ti.ak sian$sis* +i+ir ti.ak peah"peah* ti.ak a.a gangguan menean* ti.ak a.a gigi +eru+ang* i.ah simetris e! Teinga: Ti.ak a.a gangguan pen.engaran* ti.ak a.a esi* teinga simetris* ti.ak a.a serumen ,! eher: Simetris* ter.apat tekanan ena )uguaris

3! Th$rak 9 Da.a:



(antung

- Inspeksi: ti.ak tampak getaran itus $r.is!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! - Papasi: terasa getaran itus $r.is .i I6S ? sisi sinistra agak me.ia .ari inea mi.aikuaris sinistra

- Perkusi: +un/i )antung .uness atau pekak atau re.up

-  Auskutasi: S1 .an S2 tungga 8S1 ter)a.i saat permuaan s/st$e .an S2 saat permuaan .iast$e ter.apat ga$p Paru



- Inspeksi: simetris* +entuk .an p$stur n$rma* warna kuit sama .engan kuit ain* ti.ak sian$sis* ti.ak a.a pem+engkakan

- Papasi: integritas kuit +aik* ti.ak a.a n/eri tekan* ekspansi simetris* takti ,remitus en.erung se+eah kanan e+ih tera+a

- Perkusi: suara paru res$nan -  Auskutasi: ti.ak a.a r$nhi* wheeing* suara na,as esikuer ! Pa/u.ara 9 -etiak  Ti.ak terka)i

5! Punggung 9 Tuang


+engkak 

 Auskutasi: suara +ising usus 7@menit Papasi: ti.ak tera+a t$n)$an* ti.ak a.a n/eri tekan* ti.ak a.a massa* ti.ak ter.apat



penumpukan airan Perkusi: suara timpani



7! enetaia 9 Anus 

Inspeksi: kuit n$rma* muk$sa em+a+* ti.ak a.a pus



Papasi: n/eri .i area pr$stat* n/eri tekan tumpu men)aar!!

#! =kstermitas 8kekuatan $t$t* k$ntraktur* .e,$rmitas* e.ema* uka* n/eri* pergerakan 

 Atas: 5@5* "@"* "@"* "@"* J@J* "@"* J@J


H! Sistem Ne$r$$gi Re,ek neur$$gi .aam +atas n$rma

10! -uit 9 -uku 

-uit: kuit ti.ak a.a sian$sis* ti.ak a.a esi* turg$r kuit n$rma* )aringan n$rma ti.ak a.a parut* suhu ekstremitas n$rma* tekstur n$rma* ti.ak a.a .ia,$resis



-uku: +ersih ti.ak a.a tan.a )ari ta+uh* ti.ak a.a sian$sis* 6RT E 3 .etik

S. &asil Pe)eriksaan Penun/an TER"A'PIR

T. Tera*i Drip ,ur$semi.!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 10 mg@)am .aam 100  ns In)eksi ans$pra$e!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 30 mg In)eks $en$!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 20*'  .e,$in!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 0*25 mg  ASA !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 110 g ISDN!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 25 mg +riinta!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! H0 mg at$rastatin!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!  g $n$r

!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 1*25 g

0. Perse*si Klien Terhada* Penyakitnya -hawatir karena menganam n/awa! 1. Kesi)*ulan Pasien mengaami n/eri .a.a .an sesak! Pasien .i.iagn$sa AD4! W.Perenanaan Pulan 

Tu)uan puang: puang ke rumah



Transp$rtasi puang: .engan m$+i



Dukungan keuarga: ukup +aik $eh istri .an anak



 Antisipasi +antuan +ia/a seteah puang:


 Antisipasi masaah perawatan .iri setaah puang: .i+antu keuarga



Peng$+atan: $+at $ra



Rawat )aan ke: RSSA



4a"ha /ang peru .iperhatikan .i rumah: mem+atasi akti,itas +ere+ih



-eterangan ain: ti.ak a.a