ASKEP ADHF

ASUHAN KEPERAWATAN PADA PASIEN DENGAN KASUS

“ACUTE DECOMPENSATED HEART FAILURE (ADHF) NON STEMI” DI RUANG ICCU PJT RSUP SANGLAH

OLEH :

NI LUH SUCI NOVI ARIANI P0712021021 D IV KEPERAWATAN TINGKAT 2 SEMESTER IV

KEMENTERIAN KESEHATAN RI POLITEKNIK KESEHATAN KESEHATAN DENPASAR  JURUSAN KEPERAWATAN TAHUN AKADEMIK 201!"201#

ASUHAN KEPERAWATAN PADA PASIEN DENGAN KASUS ADHF (ACUTE DECOMPENSATED HEART FAILURE (ADHF) NON STEMI  DI RUANG RUANG ICCU PJT RSUP SANGLAH SANGLAH

I$

 Nama Mahasiswa

: NI LUH SUCI NOVI ARIANI ARIANI

Tm!a" P#a"$

: ICCU PJT% RSUP SANGLAH

Ta&''a P&'$aia&

: ** FE+RUARI *,-. P/$/ ,01,, WITA

I%&'*+ D, K-&'

 Nama

: T& 2MS3

Ta&''a Mas/$ RS

: *- F4#/a#i *,-.

Tm!a" m!a"7T 7Taa&''a &''a Lahi Lahi##

: D&!a D&!asa sa## % 5- Ds Dsm m4 4## -859 -859

S/m4# I&;#masi

: Pa Pasi&

Um/#

: 0, Tah/& - +/a& *5 Ha#i

A'ama

: Hi&
J&is Kami&

: La$i=La$i

S"a"/s P#$awi&a&

: M M&i$ah

P&
: SMP

S / $ /% +a&'sa

: +a + ai% I&<;&sia

P$#aa&

: Ka#>awa& Swas"a

Lama +$#a

: 9, Tah/&

Aama"

: J1 Na$/a ''1 -A D&!asa#  

Dia'&;sa M
: ADHF !#;i + ?1 ACS (UAP << N1 S"mi)

 N; RM

: -90,690.

Ca#a +a>a#

: JK+M

P/$/ : ,0:*5:-6 WITA

KELUHAN UTAMA:

= K/h K/ha& a& /"a /"ama ma saa" saa" MRS MRS (*(*-7F 7F4 47* 7*,,-. . ):  N>#i #i a#a #i !a
ASUHAN KEPERAWATAN PADA PASIEN DENGAN KASUS ADHF (ACUTE DECOMPENSATED HEART FAILURE (ADHF) NON STEMI  DI RUANG RUANG ICCU PJT RSUP SANGLAH SANGLAH

I$

 Nama Mahasiswa

: NI LUH SUCI NOVI ARIANI ARIANI

Tm!a" P#a"$

: ICCU PJT% RSUP SANGLAH

Ta&''a P&'$aia&

: ** FE+RUARI *,-. P/$/ ,01,, WITA

I%&'*+ D, K-&'

 Nama

: T& 2MS3

Ta&''a Mas/$ RS

: *- F4#/a#i *,-.

Tm!a" m!a"7T 7Taa&''a &''a Lahi Lahi##

: D&!a D&!asa sa## % 5- Ds Dsm m4 4## -859 -859

S/m4# I&;#masi

: Pa Pasi&

Um/#

: 0, Tah/& - +/a& *5 Ha#i

A'ama

: Hi&
J&is Kami&

: La$i=La$i

S"a"/s P#$awi&a&

: M M&i$ah

P&
: SMP

S / $ /% +a&'sa

: +a + ai% I&<;&sia

P$#aa&

: Ka#>awa& Swas"a

Lama +$#a

: 9, Tah/&

Aama"

: J1 Na$/a ''1 -A D&!asa#  

Dia'&;sa M
: ADHF !#;i + ?1 ACS (UAP << N1 S"mi)

 N; RM

: -90,690.

Ca#a +a>a#

: JK+M

P/$/ : ,0:*5:-6 WITA

KELUHAN UTAMA:

= K/h K/ha& a& /"a /"ama ma saa" saa" MRS MRS (*(*-7F 7F4 47* 7*,,-. . ):  N>#i #i a#a #i !a
RIWA.AT PEN.AKIT: *$ R/* R/** * P&' P&'* *  S& S&*,* *,*' ' Pasi& m&'a"a$a& !a
#i "/m!/ #i a#a&' a s$i"a# * m&i" a !a#i&>a  !asi& "ia ha& >a 4#/saha /&"/$ is"i#aha" "i#i&>a)1 Pasi& : +4as  +#a"hi&' : S!;&"a& Ci#?/ /a" a"i; i;& & : = Na
=

= = =

P&
 H!a#i& 06, /&i" T7H h 5 am !$ (-61,,)  F/#;smi< 5  *, m' (IV)  Pa&";!#a; 6, m' (IV) !/$/ (--1,, Wi"a)

=

Hasi !m#i$saa& !&/&a&' sama
HG+: -5%.6 (&;#ma) A&aisa Gas Da#ah: SGOT : -,,%- SGPT : *9%80 Kimia $i&i$ : Na: -5-%8* (R&a" MRS s4/m&>a: P#&ah Pasi& a !aa$i" Maa' !asi& ha&>a a" a" P&>a$i": Pasi& m&'a"a$a !#&ah m&'aami Pasi& m&'a"a$a& "ia$i" s!#"i: = Ja&"/&' : Disa&'$a E!i!si : Disa&'$a = Hi!#"&si : Disa&'$a S"#;$ : Disa&'$a = Dia4"s Mi"/s "i! -7* :Disa&'$a Ka&$# : Disa&'$a = Kai&a& Jiwa : Disa&'$a = P&>a$i" M&/a# S$s/a : Disa&'$a = Lai&&>a := = Pasi& "ia" a#'i ma$a&a&% a" a#'i "#ha
"ia" $?$aa&1 Pasi& mmii$i #iwa>a" !#;$;$ sa$ /sia *, "ah/&
m#;$;$ sa$ *,-6 a/1 Pasi& "ia" mi&/m A$;h;1 ?1 Riwa>a" P&>a$i" K/a#'a Pasi& m&'a"a$a& "ia&' mmii$i !&>a$i" m&/a# s$s/a ma/!/& !&>a$i" m&/a# ai&>a% "ia&' m&<#i"a !&>a$i" $"/#/&a& s!#"i hi!#"&si% a&"/&'% awa& swas"a P&
SMA

Ma$a&a&% as$a& : = Lai&=ai&% as$a& : = $ K&3*+**'  : M#;$;$: A%*% K;!i : A%*8  O4a": A%* A$;h; : T%*  Ji$a >a as$a&: Pasi& mmii$i $4iasaa& mi&/m $;!i a  4/&'$/s #;$;$ &am/& sa$ "ah/& *,-6 a/ !asi& s/a&'
F#$/&si7!;#si ma$a&

: S4/m mas/$ #/mah sa$i" !asi& ma$a& 5 $ai
<&'a& !;#si - $ai ma$a& - !i#i&' >a&' 4#isi &asi% a/$
sa>/#% s"ah !asi& mas/$ 

#/mah sa$i" !asi& ma$a& 5 $ai sha#i <&'a& a&' s/
: 99 $'

Ti&''i +a
: -90 ?m

LILA (?m)

: *6

J&is ma$a&a&

: Ma$a&a& sama
IMT: *-%60659 (N;#ma -0%9=*91,)

-,, K$a % !#;"i& 90 '# <&'a& a
%$ma$a& sia&'% s&a?$% ma$a& maam <&'a& &is

ma$a&a& !a'i1

S4/m mas/$ #/mah sa$i" !asi& ma$a&

&asi% a/$ /#

&am/& a#a&' ma$a& 4/ah1

Ma$a&a& >a&'
: Da'i&' +a4i

Ma$a&a& "i
:=

Ma$a&a& !a&"a&'a&

: Da'i&' Sa!i

Mi&/m

: Pasi& S4/m MRS mi&/m sam!ai * 4;"; isia& -9,, m% Ka#&a !asi& sam4i 4$#a% &am/& s"ah MRS $a#&a $/#a&'&>a a$"i@i"as !asi& ma$a !asi& m&'a"a$a&

mi&/m&>a

4#$/#a&' a

mi&/m - 4;"; ai#

mi&#a isia& 90, m1 Saa"

 !&'$aia&
,01,,

Wi"a

!asi&

mi&/m -9, m ai# mi&#a1  Nas/ ma$a&

:

m/a7m/&"ah7sa#iawa&7<

 .* ; 3*    s
:

: T%* 

P#/4aha& ++ 5 4/a& "#a$hi# :   4#"am4ah

 .*  &*6   4#$/#a&'

I'*& C*,*' 6*+&': < < =

M'5= : 1!0 >> I'?5+ : 200 >> I&$si ;4a":=

#$ P9-* &-='*+ a. +/a&' ai# 4sa# : Pasien BAB dibantu menggunakan pispot di tempat tidur 

F#$/&si

: S4/m MRS - $ai sha#i% s"ah MRS - $ai sha#i1 Saa" !&'$aia& !asi& m&'a"a$a& 4/m +A+ sa$ MRS
Wa$"/: = Wa#&a: =

K;&sis"&si

:=

P&''/&aa& P&?aha# : Ti
: S4/m MRS !asi& +AK 7= 5=6 $ai sha#i% s"ah MRS !asi& +AK m&''/&a$a& C;&<;m $a""#
Wa#&a : Saa" !&'$aia& wa#&a /#i& !asi& $/&i&' !$a" +a/

: Khas am;&ia$ 

O565 >*,*': < < < <

U,'&@ !0 >> IWL @ 1!!!"2@ 87! >>"B*= AM (*, =&*39-+=&)@ !>>"33"B*= @!  !!@ 27! >>" B*= *-*'>& >*,*' +** 6&'*B*' : I'*&  O565 !0>>< !>>@ <>>

7$ P9-* %5, %*' +,*4*

:

W*5 %5, (B*=):  S4/m MRS !asi& is"i#aha" "i
S"ah MRS% !asi& m&'a"a$a& s/i" /&"/$ is"i#aha" &>a$ $a#&a !asi& m&'a"a$a& masih m&>s/ai$a& i&'$/&'a& ama& "i&>a$ a1 Lama "i
: Is"i#aha" "i
K4iasaa& !&'a&"a# "i
:=

K4iasaa& saa" "i
:=

Ks/i"a&
:

 =  m&a&' "i
$ P9-* &,* %*' **+

a1 K'ia"a& Dai> Li@) = P#s;&a h>'i&

: : : Di4a&"/ s4a'ia& $a#&a m&'/#a&'i !#'#a$a& !asi&

a'a# "ia <1 K'ia"a&
 4#s;$ 

 a  ma&
 a  m/
 a  m&'&a$a& !a$aia&

a

  $ P9-* K&,B* a1 J&is !$#aa&  41 J/mah am $#a ?1 Ja


a$"i@i"as : Ka#>awa& swas"a : -5 am (s"&'ah ha#i) : Pa'i ha#i sam!ai sia&' ha#i)

<1 Lai&=ai& (s4/"$a& ) : =

ssa$ &aas s"ah m&'a
II$

R/** K&5*,* G&'9,*= :

K&&,*'*' G&'9,*= : : Pasi& : P#m!/a& : La$i=La$i : M&i&''a : M&i&''a : M&i$ah

:

Ti&''a Sa"/ R/mah

Ds$#i!si : Paa "ia&' m&'ia$i" s!#"i a ma/!/& 'aa='aa ai& >a&' m&'a#ah $ a&"/&'1 Is"#i !asi& m#/!a$a& a&a$ $= * a$i" >a&' sama <&'a& !asi&% is"#i !asi& s/a m&i$ah a$i" >a&' sama <&'a& >a&' a$i" i&i m&/#/& !aa &am/& 'aa 4/m "#iha"% ""a!i $m/&'$i&a& saa "i
III$

R/** L'5'*' -1 K4#siha& : Tm!a" "i&''a !asi& mmii$i i&'$/&'a& >a&' 4#sih% <$a"

Li&'$/&'a& *1 R/mah

<&'a& sawah a sa&'a" s/$1 : K" : : J&<a : Kama# Pasi&

: Pi&"/ : Da!/#  

: Kama#  51 +aha>a

: Tia&' #awa&

61 P;/si

 4&?a&a1 : Tia&' 4#a#"i% $a#&a "i
IV$

A+6& P+9+9+*1$ P9-* 6, %*' 6&,+&6+ a1 Aa" 4a&"/ >a&'
 =  $a?a ma"a (!aa&' a s&si"ii"as "#ha
2$ P&,+&6+ %, H*- *' %6,*' +** ' : Pasi& m&'a"a$a& sa$i" a#a
is$mia !a
mi;?a#
 !/a&' /&"/$ 4isa a1 P&,53*4*' *' %,*+**' +&&-*4 +*

: Pasi& m&'a"a$a& 4a&>a$ !#/4aha& >a&'

a saah sa"/&>a "i&''a &a&'$a& shi&''a !asi& !#/  4#aa mm4/a" !asi& "iama&% !asi& /'a m&'a"a$a& "ia1

$

S5*+*'* 4*

:

Pasi& m#asa s
sm4/h
H535'*'"9=5'*+

:

O#i&"asi !asi& $/#a&' 4ai$% $;m/&i$asi

 4#a&'s/&'
+i?a#a

4ahasa /"ama

:

*4*+*

ma/i

*-

 .*  #@a&

4ahasa
 .*  mam!/ m&'$s!#si$a&  .*  mam!/ m&'#"i ;#a&' ai&  41

Tm!a" "i&''a   s&ai"/ 4#sama $/a#'a

?1 Khi
-

Aa&'
: A
-

m/s>awa#ah <&'a& $!/"/sa& 4#sama1 P;a $;m/&i$asi K/a&'a&

: +ai$% 4#a&'s/&'
<1 Ks/i"a&
K&3*+**' +&+5*-

a1

 41

Ga&''/a& h/4/&'a& s$s/a
 =  m&s"#/asi

 =  i4i<;

 =  $hamia&

 = #$si

 =  aa" $;&"#as!si Pmahama& "#ha
Pasi& "ia s?a#a $s/#/ha&% &am/& aa&'
P&,*4*'*' 96' a1 P&'am4ia& $!/"/sa&

  s&
a&'
: =

?1

a&' i&'i&
<1

a&'
 =  ?a#i !#";;&'a&

 =  ma$a&

 =  ma$a& ;4a"

 = "i
S+&= '-*  &6&,>***'

a1

Sia!a a"a/ a!a >a&' m&a
 41 A!a$ah T/ha&% A'ama% K!#?a>aa& !&"i&' /&"/$ a&
  ; *

?1 K'ia"a& A'ama a"a/ K!#?a>aa& >a&'
:

S4/m MRS% !asi& ha&>a ma$asa&a$a& $'ia"a& a'ama s!#"i Rahi&a= Rahi&a S/?i1 S"ah MRS !asi& ha&>a 4#<;a
<1

K'ia"a& A'ama a"a/ K!#?a>aa& >a&' i&'i& a$a& Rahi&a S/?i K/&i&'a&
 4#sama $/a#'a 4sa#&>a1

V$

P&'*B*' F+   A$ V*- S'

T$a&a&
: 5.%9;C

 Na
: .7m

RR

: -0 7m

$ K&+*%*,*'

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