LAPORAN KASUS
ASUHAN KEPERAWATAN PADA PASIEN DENGAN HERNIA INGUINALIS LATERALIS SINISTRA DI RUANG BOUGENVIL RUMAH SAKIT UMUM DAERAH Dr. Dr. M. SOEW SOEWANDHI ANDHI SURABAYA Tanggal 22 s/d 2 O!"#$%r 2&'
LEMBAR PENGESAHAN
ASUHAN KEPERAWATAN PADA PASIEN DENGAN HERNIA INGUINALIS LATERALIS SINISTRA DI RUANG BOUGENVIL RUMAH SAKIT UMUM DAERAH Dr. M. SOEWANDHI SURABAYA Tanggal 22 s/d 2 O!"#$%r 2&'
Ol%( ) Ed*+n R%,a K-s-a N+ ) '.&&2&
PENGKA0IAN KEPERAWATAN ASUHAN KEPERAWATAN MEDIKAL BEDAH STIKES HANG TUAH SURABAYA
N, ,!-#- Tg/(, eng*(#n D#gn3- ,e)#-
'. IDENTITAS
1. N, 2. U,"% 7. 8en#- *e,#n 4. Stt"5. Ag, :. S"*"/&ng- ;. B!- <. Pen)#)#*n . Pe*e%(n
Tg/(, MRS N3. RM R"ngn/*e E)#n Re K"-", N3.*,% 22 O*t3&e% 2014/1.00 HIL He%n# Ing"#n#- Lte%6
Tn. G 57 t! *#9*# Men#*! I-, 8/In)3ne-# In)3ne-# STM K%'n PT.===
2291092014/*. 14.00 2<9>>9>>9>>> Te%t#/*e- II 21: ?
P-#en t#)* ,e,##*# e%g# ,*nn$ ,#n",n )n 3&t 9 3&tn . POLA 1UNGSI KESEHATAN '. P%rs%s+ T%r(ada K%s%(a"an 3K%4a!+nan T%r(ada K%s%(a"an 5 Sa!+"n4a6
P-#en ,engt*n &! en'*#t te%-e&"t ,-#! &#- -e,&"!. Se#n #t" -#en ("g
&e%!% g% -ege% "ng )n *e,&# g# )engn *e-e!%#nn' 2. P#la A!"+7+"as Dan La"+(an
. Ke,,"n e%tn )#%# A*t#@#tMn)# Be%*#n/&e%)n)n E#,#n-#/t3#et#ng M3&##t- )# te,t t#)"% Be%#n)! Be%(n N#* tngg Be%&en( Me,-* Pe,e#!%n %",!
0 9 9
SMRS 1 2 7
4
0 9 9 9
MRS 1 2 7
4
. P#la N-"r+s+ 8 M%"a$#l+!
. P3 ,*n D+ r-a(
D+ r-a( sa!+"
F%e*"en-# 794>/-e!%# F%e*"en-# 7> -e!%# 8en# n-# 8en# n-# P3%-# 1 #%#ng !&#P3%-# 1 #%#ng !&#Pntngn 9 M*nn )#-"*# Se," -"* N-" ,*n )# RS 6 n3%, 6 &e%t,&! 6 &e%*"%ng 6 ," 6 ,"nt!$ .............. 6 -t3,t#t#Ke-"#tn ,enen 6 t#)* 6 ' G#g# -" 6 t#)* 6 ' NG t"&e 6 t#)* 6 ' &. P3 ,#n", D+ r-a(
F%e*"en-# 8en#8",! Pntngn M#n",n )#-"*#
795>/!%# A#% P"t#! 2000/24(, T#)* ) Se," -"*
D+ r-a( sa!+"
F%e*"en-# 795>/!%# 8en# A#% "t#!. 8",! 2000/24(,
Ke,,"n #nte%*-# 6 -e-"# e%t#g3 6 t#)* N'e%# 6 t#)* P L"* 3-t 3e%-# !e%n#3t3,# ?en"t9en"t R -e*#t% )e%! #ng"#n#S 4 19106 T St &e%ge%* <.
6t#)*$en"%"nn *e-)%n 6 ' 6 '
P#la K#ns% D+r+
1. ?#t% )#%#
-#en ,en'"*# -e," &g#n t"&"! )n &#- ,ene%#, -et# ngg3t
t"&"!n'. 2. I)ent#t- )#%#
P-#en ,ene%#, t"g-n' -e&g# %# )n *e %",! tngg
-e%t *%'n -e&"! &%#* 7. Pe%n )#%# P-#en ,e*-n*n t"g- )n ,ene%#, )engn e%nn' -e&g# *e %",! tngg )n *%'n -e&"! &%#*. 4. I)e )#%# -#en !n' &e%!% "nt"* et -e,&"! )n &#- "ng. 5. H%g )#%# -#en &e%nggn &! ,e-*#"n -*#t tet# )# ,-#! ,e%- !%g )#%#n' &e", (t"!. .
Pntngn g, 6t#)* 6 '$ ....................... Me,#nt *"n("ngn %3!n#n 6 t#)* 6 ' . PENGKA0IAN PERSISTEM 3 Review of System6 '. Tanda@Tanda V+"al
. &. . ). e. .
S"!" N)# Te*nn )%! F%e*"en-# nT#ngg# &)n Be%t &)n
7: J? 100 /,en#t 0/;0 ,,Hg 20 /,en#t 1:; , SMRS 55*g
3*-# A># #%, Reg"e% "--# K"t 3*-# A%te%# %)###%, Reg"e%
MRS 55 *g
2. S+s"% P%rna;asan 3 Breath6
P) #n-#%-# )n e*-#%-# t,* n3%,. F%e*"en-# e%n-n 20>/,en#t$ #%, te%t"%$ ge%*n "#ng !#)"ng 96$ &ent"* )) n3%,3!e-t$ !#)"ng )n t%*e t#)* ,eng,# -",&tn )n )e@#-#$ %e,#t"- %& -, ) *#%# )n *nn )#n)#ng ))$ A)n' -"% -3n3% ) *e)" %"$ -"% %e)" ) &t- %" )n !e%$ te%)eng% -"% @e-#*"e% )# *e)" #-n %"$ -"% %3n*!# 96 )n !ee#ng t#)* ).
'. S+s"% Kard+#7as!-l%r 3 Blood 6
Bent"* )) n3%,3!e-t )en'"t (nt"ng ) #t"- 3%)#- 1 , te% ,e)#$ "--# (nt"ng t,*$ N)# <2>/,en#t$ ?RT 2)et#*$ te*nn )%! 100/<0 ,,Hg$ e%"-# !ngt$ S1 S2 t"ngg$ S7 S4 t#)* )$ #%, %eg"e%$ e*-t% -#-t3e/,"%,"% t#)* ) &en)"ngn @en ("g"%#- 96$ t#)* ) 3e)e,.
. S+s"% P%r!%+(an 3 Bladder 6
S#-te, e%*e,#!n &e%-#!$ t#)* ) )#-ten-# *n)"ng *e,#! )n t#)* ) n'e%# te*n. E#,#n-# "%#n (",! 2000 /24 (, )n %n *"n#ng. P-#en t#)* ) gngg"n ), e#,#n-# "%#ne.
. S+s"% P%n?%rnaan 3 Bowel 6
,""t )n tengg3%3*n t,* *e%#ng$ gngg"n ene%nn t#)* )$ t#)* *e,&"ng$ t#)* ) 3&-t#-# ,""n )#%e$ *#en &"ng #% &e-% 1>/!%#$ !e% t#)* te%&$ g#n( t#)* te%&$ n3%e*-#$ t#)* ) n'e%# te*n$ -"% t#,n# 6 ) &)3,en$ *e,&"ng t#)* ) -"% e** ) )e%! !e%$ e%#-tt#* n3%,$ &#-#ng "-"- 6 n3%,.
9. S+s"% M-s!-l#s!%l%"al 3 Bone6
Ke,,"n e%ge%*n -en)# &e&- )# -et# e*-t%#,#tE*-t%#,#t- t#)* ) ,-! ), e%ge%*n 5555 5555 5555 5555 T"ng Be*ng
:. S+s"% In"%g-%n
T#)* ) *e#nn
R,&"t$ *"#t *e t#)* ) &en(3n$ W%n *"#t -3 ,tng$ t#)* te%)t )e*"&#t"-$ t"%g3% &#*$ *% *"#t !ngt
SGPT
27
129;< "/L6
GDA
0
,g/)L6
BUN
15
;922 ,g/)L6
K%et#n#n
1$1
0$:91$7 ,g/)L6
2. TERAPI N3. N, 3&t 1 ?#n, 2 An&#,
D3-#1>1$5 g% 1> 1g%
8"% e,&e%#n F"ng-# Int% @en Ant#t#* Int% @en Peneg!n #ne*-#
NAMA KLIEN UMUR NO 1
Tn. G 5< t!
ANALISA DATA
R"ngn/*,% 21: ? NO RM 7<9>>9>>
DATA
PENYEBAB
MASALAH
DS P-#en ,engt*n &! -#en
P3-t 3e%-# !e%n#3t3,#
N'e%#
T#n)*n e,&e)!n
Re-#*3 t#ngg# #ne*-#
,e%-*n n'e%# ) )e%! e%"t DO P L"* 3-t 3e%-# !e%n#3t3,#
?en"t9en"t R -e*#t% )e%! #ng"#n#S 4 19106 T St &e%ge%*
2 -
D- 9 D3 te%)t "* 3e%-# -en(ng 10 , )#)e%! #ng"#n#- te%#-#n#-t%
RENANA KERPERAWATAN
N3. D#gn3- *ee%tn T"("n )n *%#te%# !-# 1 N'e%# &e%!"&"ngn Sete! )#*"*n -"!n *ee%tn 1.
)engn
3-t 3e%-# 2 > 24 (, )#!%*n -#en )t
!e%n#3t3,#
Inte%@en-#
R-#3n
K(# *e"!n n'e%#$ e%!t#*n 1. Meng#n)#*-#*n
*en"t"!n
3*-#$ #nten-#t- -* 19106$
"nt"* #nte%@en-# )n ("g tn)9
,eng"%ng# t#ng*t n'e%#.
%e*"en-# )n *t". Menn)#
tn)
K%#te%# !-#
ge(
*3,#*-#.
. M," ,eng3nt%3 n'e%#.
ge#-!$ t*#*%)#$ ,e%#ng#-.
&. P-#en
D3%3ng eng"ng*n e%-n.
%- t*"t -e!#ngg ,eng"%ng#
,e3%*n &! ne%# &e%*"%ng 7.
Be%#*n
e%-e-# *n #nten-#t- -*#t.
)engn ,engg"n*n ,n(e,en
,#-n' ,e,&$ &e%*"n("ng 7. Me,3*"-*n
n'e%#.
)n ,en3nt3n tee@#-e.
)t
,e*-n*n 2.
. P-#en )t ,engen# n'e%#.
4.
n3n@e%&
*t#@#t-
L*"*n
t#n)*n
,#-n'
!#&"%n
e%*e,&ngn/%e-3"-#
2. Dt ,eng"%ng# n-#et- )n
e%!t#n ,"ng*#n )t #t#
,#-n' eng"&!n 3-#-#$
,en#ng*t*n
-en)# 'ng -*#t.
%e*--#
/
,en"%"n*n tegngn 3t3t.
In-t%"*-#*n
-#en/)3%3ng
-#en
,engg"n*n 5. Men#ng*t*n
"nt"*
*e,,"n
"nt"* ,enngg"ng#.
,--e$ %entng ge%* ) 4. Men#ng*t*n 5.
*e,&#
@#-"#--#/&#,&#ngn #,(#n-#$
%e*--# )n
e%-n -e!t.
%e*--# %3g%e-# t" te*n#* n- ),. :.
K3&3%-# e,&e%#n nge-#*. :. Me,&e%#*n n'e%#/t#)*
en"%"nn n',n$
2
Re-#*3 t#ngg# #ne*-# -ete! )#*"*n t#n)*n 1. A-# tn)9tn) #ne*-# *ee%tn ), *t" 7 > 24 (, 2. Gnt# t ten"n )n *#n &e%!"&"ngn )engn t#)* te%()# #ne*-# ) %e &e*t#n)*n e,&e)!n -et# !%# 3e%-#. Deng *%#te%# !-# 7. Gnt# &"tn -ete! 2 !%# 3-t 9 L"* 3e%-# *e%#ng 9 T#)* ) tn)9tn) #ne*-# 3e%-# )n -en("tn' %"t#n -et# !%# )engn te*n#* -et#*/-et#*. 4. K3&3%-# "nt"* e,&e%#n 3&t nt#t#*
TINDAKAN KEPERAWATAN
,eng"%ng# )e,, Pe,nt"n tn)9tn) #ne*-# e&#! )#n# *n ,eng"%ng# en'e&%n #ne*-# -e% ,e"2. Meng!#n)%# &e%-%ngn' *",n 7. Pe%tn "* *n ,e,e%et en'e,&"!n )n ,eng%ng# %e-#*3 #ne*-# 4. Ant#t#* *n ,ene*n %e-#*3 #ne*-# )%# ), t"&"!. 1.
N3. 1$2
W*t" T#n)*n Tg/8, 229109 B#n !"&"ngn -#ng e%' )engn -#en )n 20146 *e"%g 1.00 Me*"*n eng*(#n )#),#ng# 3e! *e"%g
TT
W*t" Tg/8, 20.00
Me*"*n e,e%#*-n #-#* 20.00
Me*"*n e* tn)9tn) @#t TD 0/;0 ,,Hg N 100>/,en#t S 7:J? RR 20 >/,en#t
A M-! te%t-# -e&g#n P Inte%@en-# 1$: )# n("t*n
Me*"*n e%tn #n"-
20.75
1$2
279109 20146 15.00 15.20
S -#en ,engt*n ,-#! -e)#*#t n'e%# )# -e*#t% "* 3e%-# O Ke)n ",", -#en &#* )n *3n("ngt#@ -e)#*#t ne,#-$ TD 0/;0 ,,Hg N 100>/,en#t S 7:J? RR 20 >/,en#t
P L"* 3-t 3e%-# !e%n#3t3,# ?en"t9en"t R -e*#t% )e%! #ng"#n#S 4 19106 T St &e%ge%*
Me,&e%#*n 3-#-# -e,# 3e%
20.00
?ttn Pe%*e,&ngn
In(e*-# - An&#, 1> 1g% Me,&e%#*n !et! e)"t#3n ) -#en tentng %3-e- en'*#tn' )n -e%#ng -e%#ng ,enggnt# enn' -e%t ,en(g !'#eg#ne -#en "nt"* ,eneg! #ne*-#
20.00
1.00 Me*"*n e%tn #n"TD 100/<0 ,,Hg N <2>/,en#t S 7;$1J? RR 22 >/,en#t Me,&e%#*n !et! e)"t#3n ) *e"%g -#en tentng %3-e- en'*#t 'ng )##) -#en
S9 O Ke)n ",", -#en &#* )n *3n("ngt#@ -e)#*#t ne,#-$ TD 0/;0 ,,Hg N 100>/,en#t S 7:J? RR 20 >/,en#t A M-! te%t-# -e&g#n P Inte%@en-# 1$7$4 )# n("t*n S -#en ,engt*n n'e%# &e%*"%ng O *e)n ",", -#en 3,3- ,ent#- G?S E4 @5 M: TD 100/<0 ,,Hg N <2>/,en#t S 7;$1J? RR 22 >/,en#t
P L"* 3-t 3e%-# !e%n#3t3,# n(%e,9n(%e,
TT
1:.00
In(e*-# - An&#, 1 > 1g%
R -e*#t% )e%! #ng"#n#S 2 19106 T St &e%ge%*
Penggnt#n #n"-n - Sn,3 Me,&e%#*n )#-!%ge nn#ng "nt"* e%-#n KRS &e-3* &e%" 1.8ngn ,engng*t &e&n &e%t 2.Men(g *e&e%-#!n "* 3-t 3e%-# 7.Mengn("%*n "nt"* *3n-",-# ,*nn t#ngg# %3te#n %en)! e,* 7
249109 20146 14.00 P-#en "ng
A M-! te%t-# -e&g#n P Inte%@en-# : )#n("t*n 20.00
S -#en ,engt*n &! &)nn' e&#! -eg% )%# -e&e",n' O *e)n ",", -#en 3,3- ,ent#- G?S E4 @5 M: TD 100/<0 ,,Hg N <2>/,en#t S 7;$1J? RR 22 >/,en#t
A ,-! te%t-# P #nte%@en-# )#!ent#*n %enn KRS &e-3*
