Asuhan Keperawatan Chelpagia ( Sakit Kepala )

ASUHAN KEPERAWATAN CHEPALGIA (SAKIT KEPALA)

A. PENG PENGKA KAJI JIAN AN 1. IDEN IDENTI TIT TAS KLIE KLIEN N  Nama

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Umur

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Jenis e!amin

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A"ama

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A!ama#

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Suu$ %an"sa

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&. RIWA RIWA'AT KESEHAT KESEHATAN a.

Ke!u !uan u# u#ama Sai# ea!a

 %. Ri*a+a# e!uan u#ama

,. Ri*a+ Ri*a+a# a# ese esea# a#an an #er #er-a -au u!u !u

-. Ri*a+ Ri*a+a# a# ese esea# a#an an e! e!ua uar" r"aa

. PEN PENGKAJ GKAJIA IAN N /ISI /ISIK  K  Pen"a0ian isi me!iu#i (D2en"es3 422r2use3 5 Geiss!er3 &61&). a. A#i A#i7i 7i#a #ass $is# $is#ir ira aa# a# Ge0a!a : •

Le#i 3!e!a3 ma!aise

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Ke#er%a#asan ai%a# ea-aan

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Ka#a"an"an ma#a 3 esu!ia#an mem%a,a3 !ema

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Ins2mnia3 %an"un a-a a"i ari -en"an -iser#ai n+eri ea!a

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Sai# ea!a +an" e%a# a-a saa# eru%aan 2s#ur #u%u 3 a#i7i#as (er0a) a#au arena eru%aan ,ua,a.

 %. Siru!asi Ge0a!a : •

Ri*a+a# ier#ensi

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Tan-a

,.

:

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Hier#ensi

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Den+u#an 7asu!er3 mis. Daera #em2ra!

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Pu,a# 3 *a0a #ama emeraan

In#e"ri#as #as e"2 e"2 Ge0a!a : •

/a,#2r8a#2r s#ress em2si2na! $!in"un"an #er#en#u.

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Perasaan e#i-amamuan 3 eu#usasaan 3 e#i-a%er-a+aan 3 -eresi.

Tan-a •

: Keua#iran (#au# aan sesua#u +an" aan #er0a-i )3 ansie#as3 ea ran"san" se!ama sai# ea!a.

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4eanisme reresi$ -eensi7e (sai# ea!a r2nis )

-. 4a 4aanan anan $, $,aira airan n Ge0a!a : •

4aan maanan +an" #in""i an-un"an 7as2a#in+a3 misa!n+a: aein3 ,2!a#3 %a*an"3 e0u3 a!,22!3 an""ur3 a-72a#3 4SG3 saus3 2#-2"3 -a"in"3 # 2ma#3 maanan  %er!ema3 0eru (a-a mi"ran).

e.

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4ua!$mun#a3 an2resia (se!ama n+eri)

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Penurunan %era# %a-an

Neur2sens2r+ Ge0a!a : •

Penin"3 -is2rien#asi (se!ama sai# ea!a )3 #i-a mamu  %er2nsen#rasi.

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Ri*a+a# e0an"3 ,e-era ea!a +an" %aru #er0a-i3 #rauma3 s#r2e3 inesi in#raarnia!3 rani2#2mi.

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Aura : 7isua!3 2!a#2rius3 #inni#us.

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Peru%aan 7isua!3 sensi#i7e #era-a ,aa+a $suara +an" eras3 ei#asis.

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Pares#esia3 e!emaan r2"resi$ ara!isi sa#u sisi

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.

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Peru%aan -a!am 2!a %i,ara $r2ses ier 

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4u-a #erseran"3 ea #era-a s#imu!us

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Penurunan re!e9 #en-2m -a!am

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Pai!!e-ema

N+er N+erii $en $en+ +aman amanan an Ge0a!a : ara#eris#i n+eri #er"an#un" #er"an#un" a-a 0enis 0enis sai# ea!a : •

4i"ren : mun"in men+e!uru a#au uni!a#era!3 e-u#aan ua#. 4un"in -imu!ai a-a see!i!in" ma#a -an $  en+e%ar e-ua ma#a

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C!us#er : ar2sisma!3 #i%a8#i%a3 #i-a %er-en+u#. %er-en+u#. Uni!a#era!3 ua#. 4en,au ma#a 3 e!iis 3 !eer3 *a0a. Hi-un" #ersum%a#3 ,airan #erumu! -i%a*a ma#a3 rin2rea3 *a0a emeraan3 %iasan+a %er!an"sun" 686 meni#3 #er0a-i eri2-e remisi.

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Ke#e"an"an 2#2# : a*i#an %er#aa3 %i!a#era!3 #erasa #er#ean3 #i-a %er-en+u#3 in#ermi#en se-an"3 r2n#28 2sii#a!3 sesa$au3 mun"in #i-a u!i -a!am *a#u !ama.

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4enin"ea! : n+eri %era#3 men+e!uru3 -an 2s#an. 4un"in men0a!ar -iarea !eer.

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Tum2r 2#a : n+eri e%a#3 mene#a3 men+e!u#u -an in#ermi#en3 serin" a!i mem%ua# asien #er%an"un. 4un"in #er!2a!isasi a-a 2sisi #er#en#u.

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Ar#eri#is #em2ra! : n+eri !!a#era! a#au %i!a#era! a-a -aera #em2ra!3 %iasan+a #a%eruran"3 -en+u# %era#3 sai#3 #erasa #er%aar.

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Pas,a#rauma#is : %er#a -an %iasan+a %ersia# r2nis3 2n#inu a#au in#ermi#en3 s#ema# a#au umum3 in#ensi#as  %era"am3 -ier%uru 2!e "an""uan "an""uan em2si2na!3  eru%aan 2sisi #u%u.

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 2sisi memer%era# sai#3 mun"in e%a#3 r2n#a! r2n#a! a#au #er0a-i a-a sa!a sa#u sisi *a0a. Ti-a menun0uan e%erasi!an -en"an en"2%a#an

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man-iri men"unaan 2%a# +an" -i0ua! %e%as a#au 2%a#8 2%a# +an" -iresean.

Tan-a : •

 N+eri3 emeraan3 u,a# a-a -aera *a0a.

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/2,us men+emi#

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/2,us a-a -iri sen-iri

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Res2n em2si2na! $eri!au #a#eraraan3 seer#i menan"is3 "e!isa.

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;#2#82#2# -aera !eer mene"an"3 ri"i-i#as nua!.

". Keamanan Ge0a!a : •

Ri*a+a# a!er"i $reasi a!er"i.

Tan-a : •

Demam (sai# ea!a menin"ea!)

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Gan""uan ,ara %er0a!an3 aras#esia3 ara!isis.

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Drainase nasa! uru!a! (sai# ea!a a-a "an""uan sinus)

. In#e In#era ras sii s2,i s2,ia! a! Ge0a!a : •

Peru%aan -a!am #an""uan" 0a*a% eran $in#erasi s2,ia! +an" %eru% un"an -en"an en+eai#.

<. PE4E PE4ERI RIKS KSAA AAN N PENU PENUNJ NJAN ANG G Pemerisaan -ia"n2s#i, : 1) R2nsen ea!a ea!a : men-e#e men-e#esi si ra#ur ra#ur -an -an en+iman" en+iman"n n s#ru#ur s#ru#ur.. &) R2nsen sinus : men"2 men"2nirm nirmasi asi -ia"n2sa -ia"n2sa sinusi#is sinusi#is -an -an men"i-en#iiasi massa!a8masa! s#ru#ur3 ma!2rmasi raan". ) Pemerisaan Pemerisaan 7isua! = e#a0aman e#a0aman33 !a>an" !a>an" an-a an-an"3 n"3 re!es re!esii

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;#a : men-e#esi masa in#raarnia!3 erin-aan 7en#riu!er a#au em2ra"i in#raarnia!

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Sinus : men-e#esi a-an+a inesi a-a -aera sen2i-a! -ane#m2i-a!

?)

4RI : men-e#esi men-e#esi !esi !esi $a%n2rm $a%n2rma!i#as a!i#as 0arin" 0arin"an3 an3 mem%eri mem%erian an in2rmasi #en#an" %i2imia3 isi2!2"is -an s#ru#ur ana#2mis.

@) E2ensea!2 E2ensea!2"rai "rai : men,a#a# men,a#a# erinerin-aan aan s#ru#u s#ru#urr 2#a ai%a# ai%a# #rauma3 CS3a#au sa,e 2,,u+in" !esi2n (S;L). B) E!e#r2ense E!e#r2ensea!2" a!2"rai rai = men,a#a men,a#a## a#i7i#as a#i7i#as 2#a 2#a se!ama se!ama %er%a"ai %er%a"ai a#i7i#as3 saa# eri2-e sai# ea!a. ) An"i2"rai An"i2"rai sere%ra sere%ra!! : men"i-en men"i-en#iia #iiasi si !esi 7asu!e 7asu!err (aneurism (aneurisma3 a3 ma!2rasi 3 S;L) ) HSD : !eu2si#2sis !eu2si#2sis menun0ua menun0uan n inesi3 inesi3 anemia anemia -aa# -aa# mens#imu!asi mi"ren. 16) La0u se-imen#asi se-imen#asi = mun"in n2rma!3 mene#a ar#eri#is #em2ra!3 #em2ra!3 menin"a# a-a in!amasi. 11) E!e#r2!i# : #i-a seim%an"3 seim%an"3 ierasemia3 -aa# mens#imu!asi mens#imu!asi mi"ran 1&) Pun"si !um%a! : un#u men"e7a!uasi $men,a#a# $men,a#a# enin"a#an #eanan CSS3 a-an+a se!8se! a%n2rma!3 a-a -ara3 inesi.

. DIAGN;SA DIAGN;SA KEPERAW KEPERAWA ATAN Dia"n2sa eera*a#an +an" mun,u! a-a asus ini a-a!a : 1) N+eri N+eri au# au# %eru %eru%un %un"an "an -en"an -en"an &) Resi2 #in""i #in""i 2in" 2in" in-i7i-u in-i7i-u #i-aee #i-aee#i #i %eru%un %eru%un"an "an -en"an -en"an ) Kuran" Kuran" en"e#aua en"e#auan n men"enai men"enai 2n-is 2n-isii -an e%u#u e%u#uan an en"2%a# en"2%a#an an

C. INTER INTER ENSI DAN RASI;N RASI;NAL AL

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