ASKEP STROKE PD TN A

ASUHAN KEPERAWATAN PADA TN. A
DENGAN STROKE HEMORAGIK DI RUANG UNIT STROKE
RSUP Dr. KARIADI SEMARANG

DISUSUN OLEH :
HASAN FUADI
NIM. G6B008058

PROGRAM PENDIDIKAN PROFESI NERS
PROGRAM STUDI ILMU KEPERAWATAN FAKULTAS KEDOKTERAN UNIVERSITAS DIPONEGORO
SEMARANG, JULI 2009
TINJAUAN KASUS

I. PENGKAJIAN
Tanggal masuk : 25 Juni 2009
Tanggal pengkajian : 06 Juli 2009
Nomor register : 6059678
Diagnosa Medis : Stroke Hemorragik

A. Identitas Klien
Nama : Tn. A
Jenis kelamin : Laki - laki
Usia : 56 tahun
Pendidikan : SMA
Pekerjaan : Swasta
Status perkawinan : Sudah Menikah
Suku bangsa : Jawa
Agama : Islam
Alamat : Grobogan

Penanggung jawab klien
Nama : Ny. M
Pendidikan : SMA
Pekerjaan : IRT
Alamat : Grobogan
Hubungan dengan klien : Istri

B. Status Riwayat Kesehatan
1. Keluhan Utama
E4 M5 V afasia

2. Riwayat Kesehatan Sekarang
Klien ditemukan oleh keluarga dalam kondisi tidak sadar dan muntah
di tempat tidur. Kemudian klien dibawa ke RSUD Purwodadi selama 1
hari. Karena tidak ada perubahan, maka oleh keluarga klien
dipindahkan ke RSUP Dr. Kariadi Semarang dengan keluhan lemas
separuh badan kanan, sulit diajak berkomunikasi, dan mengalami
penurunan kesadaran, GCS: E2 M5 V afasia. Sebelum dilakukan
pengkajian di Unit Stroke pada tanggal 06 Juli 2009 pada Tn. A
telah dilakukan tindakan di UGD yaitu diberikan infus RL 20 tpm,
terapi oksigen tambahan 3L/menit, pemeriksaan EKG ( hasilnya sinus
takikardia), CT-scan, dan fotothoraks. Terapi injeksi dan oral
dilanjutkan di dalam ruang Unit Stroke.
3. Riwayat Kesehatan Dahulu
Keluarga mengatakan klien belum pernah mengalami stroke sebelumnya,
klien mempunyai riwayat hipertensi yang tidak terkontrol. Klien
tidak memiliki riwayat DM, jantung dan asma.
4. Riwayat Kesehatan Keluarga
Tidak ada anggota keluarga yang mempunyai penyakit serupa seperti
Tn. A

C. Genogram

Tn. A adalah anak pertama dari empat bersaudara, mempunyai lima orang
anak yang ketiga anaknya yang terakhir masih tinggal serumah dengan
Tn. A. Tidak mempunyai riwayat penyakit menular maupun riwayat
penyakit keturunan.
D. Pemeriksaan Fisik
1. Kepala dan Leher
"Tanggal "06 Juli 2009 "07 Juli 2009 "09 Juli 2009 "
"Bentuk "Mesochepal, "Mesochepal, "Mesochepal, "
" "simetris "simetris "simetris "
"Rambut "Penyebaran "Penyebaran merata,"Penyebaran merata,"
" "merata, ketebalan"ketebalan cukup, "ketebalan cukup, "
" "cukup, warna "warna hitam "warna hitam "
" "hitam " " "
"Mata "Konjunctiva tidak"Konjunctiva tidak "Konjunctiva tidak "
" "anemis, sclera "anemis, sclera "anemis, sclera "
" "tidak ikterik, "tidak ikterik, "tidak ikterik, "
" "pupil anisokor, "pupil anisokor, "pupil anisokor, "
" "diameter pupil 3 "diameter pupil 3 "diameter pupil 2 "
" "mm "mm "mm "
"Telinga "Bersih, simetris,"Bersih, simetris, "Bersih, simetris, "
" "tidak terdapat "tidak terdapat "tidak terdapat "
" "seruman "seruman "seruman "
"Hidung "Bersih, simetris,"Bersih, simetris, "Bersih, simetris, "
" "tidak ada napas "tidak ada napas "tidak ada napas "
" "cuping hidung "cuping hidung "cuping hidung "
"Mulut "Lidah tidak "Lidah tidak kotor,"Lidah tidak kotor,"
" "kotor, mukosa "mukosa lembab "mukosa lembab "
" "lembab " " "
"Leher "Tidak ada "Tidak ada "Tidak ada "
" "pembesaran "pembesaran "pembesaran "
" "kelenjar limfe "kelenjar limfe dan"kelenjar limfe dan"
" "dan tiroid "tiroid "tiroid "

2. Jantung
"Inspeksi "IC tidak tampak "IC tidak tampak "IC tidak tampak "
"Palpasi "IC teraba di SIC "IC teraba di SIC "IC teraba di SIC "
" "V, 2 cm LMCS "V, 2 cm LMCS "V, 2 cm LMCS "
"Perkusi "Pekak "Pekak "Pekak "
"Auskultasi "BJ I/II murni, "BJ I/II murni, "BJ I/II murni, "
" "tidak ada "tidak ada gallops,"tidak ada gallops,"
" "gallops, tidak "tidak ada mur-mur "tidak ada mur-mur "
" "ada mur-mur " " "

3. Paru
"Inspeksi "Simetris, tidak "Simetris, tidak "Simetris, tidak "
" "ada retraksi "ada retraksi "ada retraksi "
" "dinding dada, "dinding dada, "dinding dada, "
" "tidak ada "tidak ada "tidak ada "
" "penggunaan otot "penggunaan otot "penggunaan otot "
" "bantu napas "bantu napas "bantu napas "
"Palpasi "Stem fremitus "Stem fremitus "Stem fremitus "
" "kanan = kiri "kanan = kiri "kanan = kiri "
"Perkusi "Sonor seluruh "Sonor seluruh "Sonor seluruh "
" "lapang paru "lapang paru "lapang paru "
"Auskultasi "Suara dasar "Suara dasar "Suara dasar "
" "vesikuler, tidak "vesikuler, tidak "vesikuler, tidak "
" "ada suara "ada suara tambahan"ada suara tambahan"
" "tambahan " " "

4. Abdomen
"Inspeksi "Datar, tidak ada "Datar, tidak ada "Datar, tidak ada "
" "jejas, tidak ada "jejas, tidak ada "jejas, tidak ada "
" "asites "asites "asites "
"Auskultasi "Bising usus, "Bising usus, "Bising usus, "
" "normal, 5x / "normal, 5x / menit"normal, 5x / menit"
" "menit " " "
"Palpasi "Tidak ada nyeri "Tidak ada nyeri "Tidak ada nyeri "
" "tekan, tidak ada "tekan, tidak ada "tekan, tidak ada "
" "hepato/splenomega"hepato/splenomegal"hepato/splenomegal"
" "li "i "i. "
"Perkusi "Thympani "Thympani "Thympani "

5. Ekstremitas
1. Ekstremitas Atas
"Tanggal "Kanan "Kiri "
" "Kesemutan "Edema "
" "Kesemutan "Edema "Baal "
"Tekanan Darah (mmHg)"130/90 "140/90 "140/90 "
"Nadi "Frekuensi"85 "85 "85 "
"(kali/meni" " " " "
"t) " " " " "
" "Irama "Teratur "Teratur "Teratur "
" "Regangan "Teraba kuat "Teraba kuat "Teraba kuat "
" Napas "Frekuensi"20 "20 "20 "
"(kali/meni" " " " "
"t) " " " " "
" "Irama "Teratur "Teratur "Teratur "
" "Regangan "Dangkal "Dangkal "Dangkal "
"Suhu (oC) "35 "36,3 "36 "

E. Sistem Persyarafan
1. Fungsi Serebral
"Status "Tingkat "Somnolent "Somnolent "Somnolent "
"Mental "Kesadaran " " " "
" "GCS "E4 M5 V afasia "E4 M5 V3 "E4 M5 V3 "
" "Gaya Bicara "Tidak bersuara "Pelan "Pelan "
"Fungsi "Orientasi "Sulit dinilai "Baik "Baik "
"Intelektua"Waktu " " " "
"l " " " " "
" "Orientasi "Sulit dinilai "Baik "Baik "
" "Orang " " " "
" "Orientasi "Sulit dinilai "Baik "Baik "
" "Tempat " " " "
"Daya Pikir"Spontan, "Sulit dinilai "+ "+ "
" "alamiah, " " " "
" "masuk akal " " " "
" "Kesulitan "Sulit dinilai "- "- "
" "Berpikir " " " "
" "Halusinasi "Sulit dinilai "- "- "
"Status "Alamiah dan "Sulit dinilai "- "- "
"Emosional "Datar " " " "
" "Pemarah "Sulit dinilai "- "- "
" "Cemas "Sulit dinilai "- "- "
" "Apatis "Sulit dinilai "- "- "

Ket: (-); tidak ada, (+); ada

2. Pemeriksaan Saraf Kranial
Nervus I (Olfactorius)
"Sensasi hidung "Sulit dinilai "Bisa "Bisa "
"kanan " "membedakan bau"membedakan bau"
" " "alcohol dan "alcohol dan "
" " "balsem "balsem "
"Sensasi hidung "Sulit dinilai "Bisa "Bisa "
"kiri " "membedakan bau"membedakan bau"
" " "alcohol dan "alcohol dan "
" " "balsem "balsem "

Nervus II (Optikus)
"Tanggal "06 Juli 2009"07 Juli 2009"09 Juli 2009"
"Mata Kanan "Ketajaman "Sulit "Mampu "Mampu "
" "Penglihatan "dinilai "melihat "membaca "
" " " "tetesan "tulisan dg "
" " " "infus "benar "
" "Lapang "Sulit "Mampu "Mampu "
" "Pandang "dinilai "melihat "melihat "
" " " "perawat yang"perawat yang"
" " " "datang "datang "
" "Melihat "Sulit "Mampu "Mampu "
" "Warna "dinilai "menyebutkan "menyebutkan "
" " " "warna "warna "
" " " "tertentu dg "tertentu dg "
" " " "benar "benar "
"Mata Kiri "Ketajaman "Sulit "Mampu "Mampu "
" "Penglihatan "dinilai "melihat "membaca "
" " " "tetesan "tulisan dg "
" " " "infus "benar "
" "Lapang "Sulit "Mampu "Mampu "
" "Pandang "dinilai "melihat "melihat "
" " " "perawat yang"perawat yang"
" " " "datang "datang "
" "Melihat "Sulit "Mampu "Mampu "
" "Warna "dinilai "menyebutkan "menyebutkan "
" " " "warna "warna "
" " " "tertentu dg "tertentu dg "
" " " "benar "benar "

Nervus III (Okulomotorius)
"Mata Kanan"Bentuk "Pupil bulat, "Pupil bulat, "Pupil bulat, "
" " "isokor "isokor "isokor "
" "Besar "Diameter 3 mm "Diameter 3 mm "Diameter 2 mm "
" "Pupil " " " "
" "Reflek "Reflek + "Reflek + "Reflek + "
" "Cahaya " " " "
"Mata Kiri "Bentuk "Pupil bulat, "Pupil bulat, "Pupil bulat, "
" " "isokor "isokor "isokor "
" "Besar "Diameter 2 mm "Diameter 2 mm "Diameter 2 mm "
" "Pupil " " " "
" "Reflek "Reflek + "Reflek + "Reflek + "
" "Cahaya " " " "

Nervus IV (Trochlearis)
"Mata "Pergerakan " " " "
"Kanan "mata ke atas"Sulit dinilai "Mampu "Mampu "
" "dan ke bawah" " " "
"Mata "Pergerakan " " " "
"Kiri "mata ke atas"Sulit dinilai "Mampu "Mampu "
" "dan ke bawah" " " "

Nervus V ( Trigeminus)
"Membuka Mulut "Mampu "Mampu "Mampu "
"Mengunyah "Mampu "Mampu "Mampu "
" "Mampu "Mampu "Mampu "
"Menggigit " " " "
" "Baik "Baik "Baik "
"Reflek Kornea " " " "
"Sensasi pd wajah "Baik "Baik "Baik "
"dengan benda kasar, " " " "
"halus, tumpul, " " " "
"runcing " " " "

Nervus VI (Abducen)
"Mata "Pergerakan " "Mampu "Mampu "
"Kanan "mata "Sulit dinilai" " "
" "lateral " " " "
" "Melihat " "Mampu "Mampu "
" "kembar "Sulit dinilai" " "
"Mata "Pergerakan " "Mampu "Mampu "
"Kiri "mata "Sulit dinilai" " "
" "lateral " " " "
" "Melihat " "Mampu "Mampu "
" "kembar "Sulit dinilai" " "

Nervus VII (Fasialis)
"Mengerut dahi " "Tidak Mampu "Tidak Mampu "
" "Sulit dinilai " " "
"Tersenyum " "Tidak Mampu "Tidak Mampu "
"Mengangkat alis" "Tidak Mampu "Tidak Mampu "
"Menutup mata " "Mampu "Mampu "
"Rasa kecap 2/3 " "Baik "Baik "
"anterior lidah "Sulit dinilai " " "

Nervus VIII (Vestibulochoclearis)
"Telinga "Suara "Sulit dinilai"Mampu "Mampu "
"Kanan "bisikan " " " "
" "Detik "Sulit dinilai"Mampu "Mampu "
" "arloji " " " "
"Telinga "Suara "Sulit dinilai"Mampu "Mampu "
"Kiri "bisikan " " " "
" "Detik "Sulit dinilai"Mampu "Mampu "
" "arloji " " " "

Nervus IX (Glossopharyngeus)
"Reflek muntah " "Baik "Baik "
" "Baik " " "
"Merasakan pahit" "Baik "Baik "

Nervus X (Vagus)
"Menelan "Sulit dinilai "Baik "Baik "
"Bicara "Sulit dinilai "Baik "Baik "

Nervus XI (Accesorius)
"Mengangkat "Kanan "Sulit dinilai "Tidak mampu "Tidak mampu "
"bahu " " " " "
" "Kiri "Sulit dinilai "Mampu "Mampu "
"Pergerakan "Kanan "Sulit dinilai "Mampu "Mampu "
"kepala " " " " "
" "Kiri "Sulit dinilai "Mampu "Mampu "

NervusXII (Hypoglasus)
"Menjulurkan lidah "Sulit dinilai "Mampu "Mampu "
"Menggerak-ka"Ke "Sulit dinilai "Tidak mampu "Tidak mampu "
"n lidah "kanan " " " "
" "Ke kiri"Sulit dinilai "Tidak mampu "Tidak mampu "
"Tremor "Tidak ada "Tidak ada "Tidak ada "

3. Pemeriksaan Sistem Motorik
"Kekuatan "Ektremita"Kanan = 0 "Kanan = 0 "Kanan = 0 "
"otot "s atas "Kiri = 5 "Kiri = 5 "Kiri = 5 "
" "Ekstremit"Kanan = 0 "Kanan = 0 "Kanan = 0 "
" "as bawah "Kiri = 5 "Kiri = 5 "Kiri = 5 "
"Keseimbangan"Tangan "Sulit untuk "Sulit untuk "Sulit untuk "
"dan "kanan "dinilai "dinilai "dinilai "
"koordinasi " " " " "
" "Tangan "Sulit untuk "Baik "Baik "
" "kiri "dinilai " " "

4. Pemeriksaan Refleks
"Refleks biseps " " " "
" "Ka = - / Ki = +"Ka = - / Ki = +"Ka = - / Ki = +"
"Refleks triseps" " " "
" "Ka = - / Ki = +"Ka = - / Ki = +"Ka = - / Ki = +"
"Refleks patella"Ka = - / Ki = +"Ka = - / Ki = +"Ka = - / Ki = +"
"Refleks achiles"Ka = - / Ki = +"Ka = - / Ki = +"Ka = - / Ki = +"

F. Sistem Integumen
"Tanggal "Warna "Turgor "Mukosa "Capilar "Kelainan "
" "kulit " "bibir "refill time " "
"06 Juli "Pigmentasi"Turgor "Mukosa " > 2 detik "Tidak ada"
"2009 ", kulit "kulit "bibir " " "
" "merata, "cukup "lembab " " "
" "warna "elastis " " " "
" "coklat, " " " " "
" "tekstur " " " " "
" "halus " " " " "
"07 Juli "Pigmentasi" "Mukosa " 2 detik "Tidak ada"
"2009 ", kulit "Turgor "bibir " " "
" "merata, "kulit "lembab " " "
" "warna "cukup " " " "
" "coklat, "elastis " " " "
" "tekstur " " " " "
" "halus " " " " "
"09 Juli "Pigmentasi" "Mukosa " 2 detik "Tidak ada"
"2009 ", kulit "Turgor "bibir " " "
" "merata, "kulit "lembab " " "
" "warna "cukup " " " "
" "coklat, "elastis " " " "
" "tekstur " " " " "
" "halus " " " " "

G. Sistem Imunitas
Tidak terdapat pembesaran kelenjar limfe dan kelenjar thyroid.
Leukosit 17,10 (26/06/09)

H. Status Nutrisi
a. Antropometri
Sebelum masuk rumah sakit: (2 bulan yang lalu)
BB : Sulit dinilai TB : Sulit dinilai
LILA : Sulit dinilai
Saat Dirawat:
BB : 65 kg TB : 165 cm LILA : 25 cm
IMT ( Indeks Massa Tubuh )
Nilai standar IMT
"Nilai "Kategori "
"<20 "Underweigh"
" "t "
"20-25 "BB normal "
"25-30 "Overweight"
">30 "Obesitas "

IMT = BB (kg)
TB (m) ²
=

= 23,8 kg/m2
Kesan: BB Normal
b. Biokimia
Hb : 16,10 gr % (26/06/09)
Albumin : gr / dl (26/06/09)
c. Penampilan fisik
Lemah, seperti orang bingung
Konjunctiva tidak anemis, sclera tidak ikterik.
d. Diit
Diit Nasi Tim

I. Status Cairan
Tabel balance cairan dalam 24 jam
"Tanggal "Intake "Output "Balance "
" " " "Cairan "
"06 Juli 2009"Infus RL 20 tpm "Urine = " "
" "=1500 "1000 " "
" "Minum "IWL = " "
" "= 800 "284 "+ 1516 cc "
" "Air dalam makanan ="Feses = " "
" "500 "- " "
" "Air hasil " " "
" "metabolisme = - " " "
" "Total input "Total output = " "
" "=2800 "1284 " "
"07 Juli 2009"Infus "Urine = " "
" "= - "800 " "
" "Minum "IWL = " "
" "= 1000 "284 "+ 416 cc "
" "Air dalam makanan = "Feses = " "
" "500 "- " "
" "Air hasil " " "
" "Total input "Total output = 1084" "
" "=1500 " " "
"09 Juli 2009"Infus "Urine = " "
" "= - "800 " "
" "Minum "IWL = "+ 216 cc "
" "= 800 "284 " "
" "Air dalam makanan ="Feses = " "
" "500 "- " "
" "Air hasil " " "
" "Total input "Total output = 1084" "
" "= 1300 " " "

J. Status Higienis
"Tanggal "Mandi "Menggosok gigi"Memotong kuku"Keramas "
"06 Juli 2009 "Dibantu "Dibantu "- "- "
"07 Juli 2009 "Dibantu "Dibantu "- "- "
"09 Juli 2009 "Dibantu "Dibantu "Dibantu "- "

K. ADL

"Tanggal"Bathing"Dressin"Toileting"Transferi"Continance"Feeding "Indek"
" " "g " "ng " " "s "
" " " " " " " "KATZ "
"06 Juli"Dibantu"Dibantu"Dibantu "Dibantu "Dibantu "Dibantu "G "
"2009 " " " " " " " "
"2009 " " " " " " " "
"2009 " " " " " " " "

Keterangan:
Indeks KATZ = G (tidak mandiri untuk semua aktivitas sehari-hari)

L. Status Eliminasi
Sebelum Masuk RS
BAB
"Frekuensi "Warna "Konsistensi "
"1X "Coklat "Lembek "

BAK
"Frekuensi "Jumlah "Warna "Nyeri "
"5-6x per "1500 cc "Kuning "- "
"hari " "jernih " "

Selama di RS
BAB
"Tanggal "Frekuensi "Warna "Konsistensi "
"06 Juli 2009 "- "- "- "
"07 Juli 2009 "1X "Coklat "Lembek "
"09 Juli 2009 "1X "Coklat "Lembek "

BAK
"Tanggal "Frekuensi "Jumlah "Warna "Nyeri "
"06 Juli 2009 "3-4 x "1000 cc "Kuning "Sulit "
" " " "jernih "dinilai "
"07 Juli 2009 "3-4 x "800 cc "Kuning "- "
" " " "jernih " "
"09 Juli 2009 "3-4 x "800 cc "Kuning "- "
" " " "jernih " "

M. Status Mobilisasi
Skor Norton 13 (kemungkinan kecil terjadi)
- Kondisi fisik umum: baik (4)
- Kesadaran: somnolent (2)
- Aktivitas: tiduran (1)
- Mobilitas: sangat terbatas (2)
- Inkontinensia: tidak terjadi (4)

Kategori skor:
16-20: kecil sekali/tidak terjadi
12-15: kemungkinan kecil terjadi
<12: kemungkinan besar terjadi

N. Status Ekonomi Kesehatan
Semua biaya perawatan selama dirawat adalah tanggungan pribadi.

O. Tindakan Kolaborasi Kesehatan
"Tanggal/Jam "Tindakan kolaboasi "Ahli "
"24 Juni 2009 "CT Scan kepala tanpa kontras "Radiologi "
"25 Juli 2009 "Pemeriksaan EKG, Rontgen Thorax "Radiologi "
"26 Juli 2009 "Pemeriksaan darah rutin "Laboratorium "
"01 Juli 2009 "CT Scan kepala tanpa kontras "Radiologi "

P. Hasil Pemeriksaan Penunjang Diagnostik
a. Hasil Laboratorium
"Pemeriksaan "Nilai Normal "Satuan "26 Juni 2009 "01 Juli 2009 "
" " " "Nilai "Ket "
" " " " "08.00 "10.00 "12.00 "14.00 "
"1. "Kalnex "Sebelum/ "Dewasa: "Fibrinolisis lokal"Insufisiensi "Jangan "Gangguan GI, "
" "(hemostati"sesudah "Kap: 1-2 kap, 3-4 "seperti epitaksis,"ginjal, hematuria "diberikan "mual, pusing, "
" "k) "makan "x/hari, Tab: 1 "prostatektomi, "karena gangguan "ke dalam "muntah, "
" "Komp: " "tab, 3-4 x/hari, "konisasi serviks, "parenkim ginjal, "darah "anorexia, "
" "Tranexamic" "Amp: 250 mg, 1-2 "edema "hamil, laktasi. "transfusi "eksanterna, "
" "acid " "amp/hr IV atau 1-2"angioneuronik " "atau "sakit kepala, "
" " " "dosis terbagi IM "herediter, " "injeksi "hipertensi "
" " " "atau 2-10 amp dgn "perdarahan " "yang "pada pemberian"
" " " "infuse drip, amp "abnormal pasca " "mengandung"IV cepat. "
" " " "500 mg 2,5-5 ml "operasi, " "penicillin" "
" " " "IV/IM terbagi "perdarahan sesudah" ". " "
" " " "dalam 1-2 dosis, "cabut gigi pada " " " "
" " " "selama atau pasca "penderita " " " "
" " " "operasi: 5-25 mg "hemofilia. " " " "
" " " "dgn infuse bila " " " " "
" " " "perlu. " " " " "
"2. "Nimotop " " "Antagonis Calsium "Hipersensitivitas " " "
" " " " "diindikasikan " " " "
" " " " "untuk terapi " " " "
" " " " "defisit neurologis" " " "
" " " " "iskemik pada " " " "
" " " " "perdarahan sub " " " "
" " " " "arachnoid " " " "
" " " " "traumatik dan " " " "
" " " " "spontan. " " " "
"3. "Ranitidin "Sebelum/ "Dewasa : "Tukak lambung, "Hipersensitivitas " "Diare, nyeri "
" " "sesudah "Injeksi IM,IV atau"tukak usus 12 " " "otot, pusing, "
" " "makan "intermiten : 50 mg"jari, refluk " " "timbul ruam "
" " " "setiap 6-8 jam, "esofagitis, " " "kulit, malaise"
" " " "dosis tidak lebih "hipersekresi " " "dan nausea, "
" " " "dari 400 mg per "patologis " " "konstipasi, "
" " " "hari. "gastrointestinal. " " "penurunan "
" " " "Tablet : tukak " " " "jumlah sel "
" " " "usus 12 jari : 150" " " "darah putih "
" " " "mg 2x sehari atau " " " "dan platelet "
" " " "2x150 mg 1x sehari" " " "pada sejumlah "
" " " "selama 4-8 minggu " " " "penderita. "
"4. "Simvastati"Sebelum/ " "Untuk menurunkan " " " "
" "n "sesudah " "kolesterol " " " "
" " "makan " " " " " "
"5. "Norvaks "Sebelum/ "Hipertensi: Dosis "Hipertensi terapi "Hipersensitivitas "Hati- hati"Sakit kepala, "
" " "sesudah "awal 1xsehari 5 "tunggal atau "terhadap "pada "udema, letih, "
" " "makan "mg, dapat "ganda, terapi "dehidropiridina "pasien "somnolensi, "
" " " "dinaikkan hingga "tunggal untuk " "dengan "nyeri perut, "
" " " "dosis maksimum 10 "kontrol tekanan " "gangguan "mual, kulit "
" " " "mg "darah, terapi " "fungsi "memerah, "
" " " " "ganda dapat " "hepar, "palpitasi dan "
" " " " "dikombinasikan " "gagal "mulut kering. "
" " " " "dengan diuretikum " "ginjal, " "
" " " " "tiazida, terapi " "gagal hari" "
" " " " "isema miokardia, " "kongestif," "
" " " " "termasuk angina " "dan pasien" "
" " " " "dan atau " "lanjut " "
" " " " "vasospasmus/ " "usia. " "
" " " " "vasokonstriksi " " " "
" " " " "koroner. " " " "
"6. "Amoxicilli"Sebelum/ "Dewasa dan anak BB"Infeksi saluran "Hipersensitivitas " " "
" "n "sesudah "kurang dari 20 kg:"pernafasan, " " " "
" " "makan "25-75 mg/kg "infeksi daluran " " " "
" " " "BB/hari dibagi 3x "kemih dan kelamin," " " "
" " " "pemberian "infeksi lain: " " " "
" " " " "salmonella, " " " "
" " " " "shigella, kulit, " " " "
" " " " "luka selulitis, " " " "
" " " " "furunkulis. " " " "
II. ANALISA DATA
"Tgl "No "Data Fokus "Problem "Etiologi "TTD "
"06'07' "1 "DS: - "Perfusi "Interupsi " "
"09 " " "jaringan "aliran darah" "
" " "DO: "serebral ": hemoragik " "
" " "GCS E4 M5 Vafasia "tidak "serebral " "
" " "Tingkat kesadaran "efektif " " "
" " "somnolent " " " "
" " "Kekuatan otot " " " "
" " "ekstremitas superior " " " "
" " "ka=ki 0/5, ekstremitas " " " "
" " "inferior ka=ki 0/5 " " " "
" " "Hemiplegi ektremitas " " " "
" " "dextra " " " "
" " "Capillary refill > 2dtk " " " "
" " "CT Scan kepala tanpa " " " "
" " "kontras (01 / 07 / 09) " " " "
" " "Kesan : " " " "
" " "Tampak perdarahan pada " " " "
" " "pedunkules cerebri kiri," " " "
" " "mesencephalon kiri dan " " " "
" " "thalamus kiri tetapi " " " "
" " "densitas dan volumenya " " " "
" " "berkurang. " " " "
" " "Udem perifokal lebih " " " "
" " "luas. " " " "
" " "Efek massa masih tampak." " " "
"06'07' "2 "DS: - "Kerusakan "Kerusakan " "
"09 " "DO: "mobilitas "neoromuskule" "
" " "Penampilan umum lemah "fisik "r,penurunan " "
" " "Kekuatan otot " "kekuatan " "
" " "ekstremitas superior " "otot " "
" " "ka=ki 0/5, ekstremitas " " " "
" " "inferior ka=ki 0/5 " " " "
" " "Hemiplegi ektremitas " " " "
" " "dextra " " " "
" " "Indeks KATZ = G (tidak " " " "
" " "mandiri untuk semua " " " "
" " "aktivitas sehari-hari) " " " "
" " "Reflek biseps ka=ki " " " "
" " ":+/++ " " " "
" " "Refleks triseps ka=ki " " " "
" " ":+/++ " " " "
" " "Refleks patela ka=ki " " " "
" " ":+/++ " " " "
" " "Refleks asciles ka=ki " " " "
" " ":+/++ " " " "
"06'07' "3 "DS: - "Kerusakan "Penurunan " "
"09 " " "komunikasi "sirkulasi " "
" " "DO: "verbal "serebral, " "
" " "Ketidakmampuan berbicara" "parese N VII" "
" " "dan menyebutkan " " " "
" " "kata-kata " " " "
" " "( afasia) " " " "
" " "Kontak mata tidak ada " " " "
" " "Parese nervus kranial " " " "
" " "VII dekstra sentral dan " " " "
" " "XII dekstra sentral " " " "
" " "CT Scan kepala tanpa " " " "
" " "kontras (01 / 07 / 09) " " " "
" " "Kesan : " " " "
" " "Tampak perdarahan pada " " " "
" " "pedunkules cerebri kiri," " " "
" " "mesencephalon kiri dan " " " "
" " "thalamus kiri tetapi " " " "
" " "densitas dan volumenya " " " "
" " "berkurang. " " " "
" " "Udem perifokal lebih " " " "
" " "luas. " " " "
" " "Efek massa masih tampak." " " "

III. PRIOROTAS DIAGNOSA KEPERAWATAN
1. Perfusi jaringan serebral tidak efektif berhubungan dengan interupsi
aliran darah : hemoragik serebral.
2. Kerusakan mobilitas fisik berhubungan dengan kerusakan neoromuskuler,
penurunan kekuatan otot.
3. Kerusakan komunikasi verbal berhubungan dengan penurunan sirkulasi
serebral, parese N VII.
.
IV. PRIORITAS DIAGNOSA KEPERAWATAN
"No. "Diagnosa Keperawatan "Tanggal "Tanggal "
"Dx. " "Ditemukan "Teratasi "
"1. "Gangguan perfusi jaringan serebral "06 Juli 2009 "- "
" "berhubungan dengan interupsi aliran" " "
" "darah: hemoragi akibat perdarahan " " "
" "pada hiperdens pada ganglia basalis" " "
" "kiri sampai korona radiata kiri. " " "
"2. "Kerusakan mobilitas fisik "06 Juli 2009 "- "
" "berhubungan dengan kelemahan " " "
" "neuromuskuler: paralisis akibat " " "
" "perdarahan pada pedunkules cerebri " " "
" "kiri, mesencephalon kiri dan " " "
" "thalamus kiri " " "

V. RENCANA KEPERAWATAN
"Tgl/ "No."Tujuan & Kriteria Hasil "Intervensi "TTD "
"jam "Dx." " " "
"06'07' "1 " Setelah dilakukan "Mandiri " "
"09 " "tindakan keperawatan "Monitor tekanan darah. " "
" " "selama 3x7 jam diharapkan"Letakkan kepala dengan " "
" " "perfusi jaringan serebral"posisi agak ditinggikan " "
" " "adekuat dengan kriteria "(30o) dan dalam posisi " "
" " "hasil: "anatomis. " "
" " "Menunjukkan peningkatan "Tinggikan tangan dan kepala." "
" " "tingkat kesadaran menjadi"Pertahankan keadaan tirah " "
" " "CM "baring. " "
" " "Menunjukkan tekanan darah"Catat status neurologis. " "
" " "dalam rentang normal (120"Kolaborasi " "
" " "– 140/60 – 90 mmHg) "Berikan O2 tambahan sesuai " "
" " "Tidak ada tanda-tanda "indikasi. " "
" " "peningkatan TIK " " "
"06'07' "2 "Setelah dilakukan "Mandiri " "
"09 " "tindakan keperawatan "Kaji kemampuan " "
" " "selama 3x7 jam diharapkan"fungsional/luasnya kerusakan" "
" " "kerusakan mobilitas fisik"awal dan dengan cara yang " "
" " "dapat diminimalkan, "teratur. " "
" " "dengan kriteria hasil: "Latih melakukan latihan " "
" " "Klien dapat duduk tanpa "rentang gerak aktif dan " "
" " "bantuan. "pasif pada semua " "
" " "Klien dapat makan dan "ekstremitas. " "
" " "minum secara mandiri. "Sokong ekstremitas dalam " "
" " "Klien dapat melakukan ROM"posisi fungsionalnya, " "
" " "aktif sesuai dengan "gunakan papan kaki selama " "
" " "kemampuannya. "periode paralisi flaksid. " "
" " " "Pertahankan posisi kepala " "
" " " "netral. " "
" " " "Tempatkan bantal dibawah " "
" " " "aksila untuk melakukan " "
" " " "abduksi pada tangan. " "
" " " "Posisikan lutut dan panggul " "
" " " "dalam posisi ekstensi. " "
" " " "Pertahankan kaki dalam " "
" " " "posisi normal. " "
" " " "Anjurkan pasien untuk " "
" " " "membantu pergerakan dan " "
" " " "latihan dengan menggunakan " "
" " " "ekstremitas yang tidak sakit" "
" " " "untuk menyokong/menggerakkan" "
" " " "daerah tubuh yang mengalami " "
" " " "kelemahan. " "
" " " "Kolaborasi " "
" " " "Konsultasikan dengan ahli " "
" " " "fisioterapi. " "

VI. CATATAN KEPERAWATAN
"Tanggal/"No. "Implementasi "Respon "TTD "
"jam "Dx. " " " "
"06-07-09"1 "Memberikan obat oral Nimotop "S: - " "
"14.00 " " "O: tidak ada reaksi " "
" " " "alergi " "
"14.30 "1 "Mengkaji status nerologis " " "
" " " "S: - " "
" " " "O: Kesadaran " "
" " " "somnolent, " "
"15.00 "1 "Meninggikan posisi tangan dan"E4 M5 V afasia " "
" " "kepala (30o) " " "
" " " "S: - " "
" " " "O: Klien dalam posisi" "
" " " "anatomis dengan " "
"16.00 "1 "Mempertahankan tirah baring. "kepala agak tinggi. " "
" " " " " "
" " " "S: - " "
" " " "O: Klien dalam posisi" "
"16.30 "1 "Memonitor Tanda- tanda vital "kepala agak tinggi. " "
" " " " " "
" " " "S: - " "
" " " "O: " "
" " " "TD : 130/90 mmHg " "
" " " "N : 85 x/mnt " "
"17.00 " " "R : 20 x/mnt " "
" "1 "Melatih ROM pasif "Suhu: 35 0C " "
" " " " " "
" " " "S: Keluarga " "
" " " "mengatakan tangan " "
" " " "kanan dan kaki kanan " "
" " " "belum bisa digerakkan" "
" " " "O: Klien tampak " "
" " " "kooperatif saat " "
"17.15 "2 "Melakukan inspeksi kulit "dilatih ROM " "
" " "terutama pada daerah-daerah " " "
" " "yang menonjol "S: Keluarga " "
" " "Menganjurkan keluarga untuk "mengatakan sudah " "
" " "melakukan masase secara "melakukan pijat " "
" " "hati-hati pada daerah "punggung pada klien " "
" " "kemerahan dan memberikan alat"O: " "
" " "bantu seperti bantal "Tidak terdapat luka " "
" " " "pada daerah- daerah " "
"17.30 "2 "Menganjurkan keluarga untuk "yang tertekan " "
" " "mengubah posisi minimal " " "
" " "setiap 2 jam (telentang, " " "
" " "miring) "S: Keluarga " "
" " " "mengatakan klien " "
"07/07/09"1 " "kadang minta miring " "
"14.00 " "Mempertahankan tirah baring. "kanan, miring kiri " "
" " " "O: - " "
" " " " " "
" " " "S: - " "
"14.15 "1 " "O: Klien dalam posisi" "
" " "Memberikan obat oral Nimotop "anatomis dengan " "
" " " "kepala agak tinggi. " "
"15.00 " " " " "
" " "Melatih ROM pasif "S: - " "
" " " "O: Tidak ada reaksi " "
" " " "alergi " "
" " " " " "
" " " "S: Keluarga " "
"15.15 "1 " "mengatakan sudah " "
" " "Melakukan alih baring. "melakukan ROM pasif " "
" " " "pada klien " "
"16.00 "1 " "kooperatif " "
" " "Memberikan obat oral " " "
" " "Ranitidin "S: - " "
"16.00 "1 " "kooperataf " "
" " " " " "
" " "Memonitor tekanan darah. "S: - " "
" " "Mencatat status neurologis. "O: Tidak ada reaksi " "
"16.30 "1 " "alergi " "
" " " " " "
" " "Memonitor Tanda- tanda vital " " "
" " " "TD 140/90 mmHg, GCS " "
" " " "E4M5V3, kesadaran " "
" " " "somnolent " "
" " " " " "
"16.45 "2 " "S: - " "
" " " "O: " "
" " "Melakukan alih baring "TD : 140/90 mmHg " "
" " " "N : 85 x/mnt " "
" " " "R : 20 x/mnt " "
"17.00 "2 " "Suhu: 36,3 0C " "
" " " " " "
" " "Menganjurkan keluarga klien "S: Keluarga 1 jam " "
" " "untuk membantu pergerakan dan"yang lalu sudah " "
" " "latihan dengan menggunakan "melakukan alih posisi" "
" " "ekstremitas yang tidak sakit "pada klien " "
" " "untuk menyokong/menggerakkan "O: - " "
" " "daerah tubuh yang mengalami " " "
"09/07/09"1 "kelemahan. "S: Keluarga " "
"21.00 " " "mengatakan semua " "
" " " "aktivitas klien " "
"22.00 "1 "Memonitor tekanan darah. "dibantu oelh " "
" " " "keluarga. " "
" " " "O: - " "
" " "Meninggikan posisi tangan dan" " "
" " "kepala (30o) " " "
" " " " " "
" " " " " "
" " " "S:- " "
"22.15 "1 " "O: TD : 140/90 mmHg " "
" " " " " "
" " " "S: - " "
" " "Mengkaji status neurologis. "O: " "
" " " "Klien dalam posisi " "
" " " "kepala agak tinggi " "
" " " "(30o) tampak nyaman " "
"05.30 "2 " " " "
" " " "S: " "
" " " "O: " "
" " "Mengkaji tonus otot "Kesadaran somnolent " "
" " "ektremitas "GCS E4M6V3 " "
" " " "Pandangan klien masih" "
" " " "tampak kosong " "
" " " " " "
" " " "S: - " "
" " " "O: " "
" " " "Ektremitas dextra " "
"06.00 "1,2 " "masih tampak lemas. " "
" " " "Tonus otot ektremitas" "
" " " "atas ka/ki 1/5 " "
" " " "Tonus otot ektremitas" "
" " "Melakukan ROM pasif maupun "bawah ka/ki 1/5 " "
" " "aktif pada klien " " "
" " " "S: Keluarga klien " "
"06.30 "1 " "mengatakan tangan dan" "
" " " "kaki kiri klien masih" "
" " " "belum bisa bergerak " "
" " " "sendiri. " "
" " "Mengukur Tanda – tanda vital "O: - " "
" " " " " "
" " " "S: " "
" " " "O: " "
"07.00 "2 " "TD : 140/90 mmHg " "
" " " "N : 85 x/mnt " "
" " " "R : 20 x/mnt " "
" " " "Suhu: 36 0C " "
" " "Mengingatkan kembali pada " " "
" " "keluarga klien untuk membantu"S: Keluarga klien " "
" " "pergerakan dan latihan dengan"mengatakan akan " "
" " "menggunakan ekstremitas yang "berusaha melatih " "
" " "tidak sakit untuk "aktivitas klien " "
" " "menyokong/menggerakkan "secara bertahap. " "
" " "daerah tubuh yang mengalami "O: - " "
" " "kelemahan. " " "

VII. CATATAN PERKEMBANGAN
"Tanggal/"No. "Evaluasi "TTD "
"jam "Dx. " " "
"06/07/09"1 "S: - " "
"21.00 " "O: " "
" " "Klien dalam posisi anatomis, kepala agak " "
" " "tinggi (30o) " "
" " "TD 130/90 mmHg " "
" " "Tingkat kesadaran somnolent " "
" " "GCS E4M5Vafasia " "
" " "Capillary Refill >2' " "
" " "A: " "
" " "Masalah perfusi jaringan serebral teratasi" "
" " "sebagian. " "
" " "P: " "
" " "Pertahankan intervensi: " "
" " "Monitor TTV " "
" " "Pertahankan posisi kepala (30o) " "
" " "Pantau status neurologis klien " "
" "2 "S: " "
" " "Keluarga mengatakan semua ADL dengan " "
" " "bantuan " "
" " "O: " "
" " "Klien tampak badrest " "
" " "Klien tampak lemah " "
" " "Kekuatan otot ektremitas atas ka=ki :1/5 " "
" " "ektremitas bawah ka=ki : 1/5 " "
" " " " "
" " "A: " "
" " "Masalah kerusakan mobilitas fisik belum " "
" " "teratasi " "
" " "P: " "
" " "Lakukan alih baring " "
" " "Monitoring daerah- daerah yang menonjol/ " "
" " "kemerahan. " "
" " "Lakukan masase " "
"07/07/09"1 "S: - " "
"21.00 " "O: " "
" " "Klien dalam posisi anatomis, kepala agak " "
" " "tinggi (30o) " "
" " "TD 130/90 mmHg " "
" " "Tingkat kesadaran somnolent " "
" " "GCS E4M5V3 " "
" " "Capillary Refill 2' " "
" " " " "
" " " " "
" " "A: " "
" " "Masalah perfusi jaringan serebral tidak " "
" " "adekuat teratasi sebagian " "
" " " " "
" " "P: " "
" " "Tinggikan posisi kepala (30o) " "
" " "Pantau status neurologis " "
" "2 "S: " "
" " "Keluarga mengatakan klien BAK sudah mulai " "
" " "ke kamar mandi tetapi masih dibantu untuk " "
" " "berjalan. " "
" " "O: " "
" " "Klien tampak badrest " "
" " "Klien masih tampak lemah " "
" " " " "
" " "A: " "
" " "Masalah kerusakan mobilitas fisik teratasi" "
" " "sebagian " "
" " " " "
" " "P: " "
" " "Lanjutkan intervensi: " "
" " "Konsultasikan dengan ahli fisioterapi " "
"09/07/09"1 "S: - " "
"07.00 " "O: " "
" " "TD 130/90 mmHg " "
" " "Tingkat kesadaran composmentis " "
" " "GCS E4M5V3 " "
" " "Capillary Refill 2' " "
" " " " "
" " "A: " "
" " "Masalah perfusi jaringan serebral tidak " "
" " "adekuat teratasi sebagian " "
" " " " "
" " "P: " "
" " "Pantau status neurologis " "
" "2 "S: " "
" " "Keluarga mengatakan sebagian ADL masih " "
" " "dibantu oleh keluarga, seperti BAK,BAB. " "
" " "O: " "
" " "Klien masih tampak lemah " "
" " " " "
" " "A: " "
" " "Masalah kerusakan mobilitas fisik teratasi" "
" " "sebagian " "
" " " " "
" " "P: " "
" " "Membantu pergerakan dan latihan dengan " "
" " "menggunakan ekstremitas yang tidak sakit " "
" " "untuk menyokong/menggerakkan daerah tubuh" "
" " "yang mengalami kelemahan. " "

-----------------------
Tn. A
56th "Stroke Hemoragic"

Keterangan :

: Laki- laki

: Perempuan

: Klien

: Tinggal serumah

ASKEP STROKE PD TN A

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