ASUHAN ASU HAN KEPERAW KEP ERAWA ATAN PADA PASIEN PASIEN DENGAN CARDIAC ARREST
OLEH : KELOMPOK V 1. 2. 3. !. 5. ". 7.
KOMA KOMANG NG YOGI YOGI CAHY CAHYA ANI LUH PUTU ARIES SETIAWATI MADE SRI OKTIARI NI KOMANG PRIYANI NI KOMANG AYU HUMALARAS S NI LUH LUH KOMA KOMANG NG TRI TRI W I MADE TEGUH WIRATANAYA
(15. (15.32 322. 2.21 2157 57)) (15.322.2158) (15.322.215) (15.322.21"2) (15.322.21"1) (15. (15.32 322. 2.21 21"3 "3)) (15.322.21"#)
SEKOLAH TINGGI ILMU KESEHATAN WIRA MEDIKA PPNI BALI
PROGRAM STUDI ILMU KEPERAWA KEPERAWATAN
2016
BAB I
PENDAHULUAN
1.1 L$%$& '$*$+, D-$$ /+/ ,$,$ 0$+%+, $+$* 4/06$/ 4$+ +0$4/ 6+$ &/4/%$ 4$+ &%$/%$ %$$. S%+,$ 4$&/ 6$/+ $+, %&4/$,+/ ,$,$ 0$+%+, $/ 6+$ $&$6$+ /46 5 %$+. P+/%/$+ 9&$/+,$ ++0**$+ &%$/%$ 5 %$+ $& "2 6$4$ 6&/$ 4$+ !2 -$+/%$. ',/% 0,$ 4+,$+ &//* +%* +4&/%$ ,$,$ 0$+%+,; 1# +%* *6* 4/ $%$ 7# %$+; 4$+ 5 +%* *6* /$ "#<" %$+ &%$ 2 +%* *6* /$ !#<5 %$+. D$%$ 4$&/ A&/=$+ H$&% A=/$%/+ S=/% (AHA) 2##3 ++0**$+; 6&$+ ,$,$ 0$+%+, $,$/ 6+$ +&++$ *$/%$ /46 6+4&/%$ 4$+ 6+$ *$%/$+ &%$$. D/ AS !;8 0%$ 6+4&/%$ 4+,$+ ,$,$ 0$+%+, 4$+ %/$6 %$+ &%$$ 55# &/. S%/$6 %$+ ,$,$ 0$+%+, +$*$+ *$%/$+ 2# &/ &$+,. M+&% '$4$+ K$%$+ D+/$ (WHO) 0$ 6+4&/%$ ,$,$ 0$+%+, +=$6$/ 22 0%$ 6$/+ 6$4$ %$+ 2##2. S4$+,*$+ 4/ I+4+/$ +&% =
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
BAB II
TINJAUAN PUSTAKA
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3. P&$4 4$+ $?%&$4
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2." P&/*$$+ 4/$,+%/* 1. E*%&*$&4/,&$
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+ 6$/+. ") P$/+ $+, %/4$* 4$6$% 4/%$+,$+/ 4/ IGD $*$+ 4/ &0* * R$ S$*/% $+, 6+$/ ?$//%$ / +,*$6.
BAB III KONSEP DASAR ASUHAN KEPERAWATAN
3.1 P+$+,$+$+ A-$
K+6 $$+ *6&$-$%$+ 6$4$ 6$/+ $+, +,$$/ +%/ 0$+%+, $& ,&$ 4/$**$+ %/+4$*$+ *6&$-$%$+ 6&%/ &/*$+ 6+$+,$+$+ $-$ +%/ 0$+%+,. P+$+,$+$+ A-$ H+%/ >$+%+, (C$&4/$= A&&%) . E6$% 0+/ &/% 0$+%+, $+, +$*$+ +%/ 0$+%+, $/% +%&/=$& ?/&/$/ (V9); +%&/=$& %$*/*$&4/$ $+, $+,$% =6$% (VT); 6 =%&/=$ $=%//% (PEA); 4$+ $/%. U+%* &%$$+ 4$&/ 6$% &/% /+/ &*$+ $+%$+ /46 4$$& '$/= L/? S66&% 4$+ $+%$+ /46 $+0%$+ A4$+=4 C$&4/$=$& L/? S66&% (ACLS) (A&/=$+ H$&% A=/$%/+ (AHA);
2##5).
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A. AIRWAY
(P$$+
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P&/$6$+ *+4// $+, +,*/+*$+ +%* 4/$**$+ R>P $4$$ %$*$+ *&$+ 6$4$ 6&*$$+ $+, *&$ 4$+ 6//*$+ 6$/+ 4$$ *+4// %&+%$+,. '&$6$ 6/+% 6+%/+, 4$$ $**$+ 6$$+ 0$$+ +$?$: 1. G+$*$+ %&/6 $+& ($4 %/%<=/+ /?% $+& +%* *$ 0$$+ +$?$ $,/ *&$+ $+, %/4$* //*/ %$+4$<%$+4$ %&$$ & 4$+ *6$$). 2. A6$/$ %&4$6$% *=&/,$$+ %&$$ &%&$ =&/=$/; 6$$+ 0$$+ +$?$ +,,+$*$+ %*+/* >$-<%&% %$+6$ *%+/ &. 3. '$*$+ 0$$+ +$?$ 4+,$+ &/*$+ $<$ $+, +$% 0$$+ +$?$ 4+,$+ ?/+,& -$ $%$ =%/+ 0/*$ $4$. '. 'REATHING
(C*
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4. K%/*$ 6$/+ 4$ +,,+$*$+ $$% $+%$+ +$?$ (ET. LMA; 4) ?&*+/ +$?$ 4/&/*$+ 8<1# +$?$+/% %$+6$ $$ +/+*&+*$+ +$?$ 4$+ *6&/ 4$4$. . A6$/$ *+4// %/4$* +,*/+*$+ +%* &/*$+ +$?$ $%$+ (/$+$ *&$+ //*/ &/-$$% 6+$*/% %&%+% /+,,$ 6++, %/4$* $$+&/* %&%$&) $*$ $**$+ *6&/ 4$4$. ?. S%$ 6&/$+ 6&+$?$$+ $%$+; ,&$ $**$+ 6+,=*$+ /&*$/ 4+,$+ +4%*/ 6$/ $&%&/ =$&%/ (%&%$* 4/$%&$ 0$*+%$+, *&/*/4). ,. P$4$ 6$/+ 4+,$+ /&*$/ 6+%$+ (6$/ %&$$) &*$+ +%/$/ 4+,$+ &$%$<&$%$ 1#<12 +$?$+/% 4+,$+ 1 +$?$ &*$+ 5<" 4%/* 4$+ %/$6 *$/ +$?$ $& 4$6$% +,$+,*$+ 4$4$. C. CIRCULATION '&$6$ $ $+, 6& 4/6&$%/*$+ 4$$ 6&%$$+*$+ /& *$/ 6$4$ $$% $**$+ &/%$/ 0$+%+, 4$+ 6$&: 1. K6&/ $+, ?*%/? 4/6&*$+ +%* 6&%$$+*$+ $/&$+ 4$&$ $$ &/%$/ 4/$**$+. 2. K6&/ $*$+ $*/$ 0/*$ 6$/+ 4/%$*$+ %&+%$+, 6$4$ $$ $+, *&$ 4$+ 6++, &$4$ 4/// 4$4$ *&$+. 3. K6&/ $+, ?*%/? 4$6$% 4/$**$+ 4+,$+ $**$+ *6&/ $+, *$% 4$+ =6$% (+%* 4-$$ 1## *$/ *6&/+/% 4+,$+ *4$$ *6&/ 2 /+=/!<5 =@ &/*$+ -$*% +%* 4$4$ +,$+, 6&+$ %$ *6&/@ *6&/ $+, 4/$**$+ $/*+$ &/%/* 4$+ &/*). !. K6&/ 4$4$ $+, $& 4/$**$+ &$$ 4+,$+ +%/$/ $6$/$ 6&+$?$$+ 4$+ /&*$/ %/4$* $4*$%. A4$6+ &$/ $+, 4/,+$*$+ 4$$ *6&/ 4$4$ 4+,$+ +%/$/ $/% 3#:2 $4$$ &4$$&*$+ *++ 4$&/ 6$&$ $/. A4$6+ 6&/+/6 */+$/ $+%$&$ *6&/ 4$4$ 4+,$+ +%/$/ $+%$&$
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5. P$4$ 6+=$&/$+ /%&$%& 4/%*$+ /$ /%$%/+: $% LOE (L O? E/4+=) !; 4$+ E6$% LOE ". 9&*+/ %/+,,/ (/ 4$&/ 1## *6&/ 6&+/%) $+$ CPR %$ 4/6$0$&/ $,$/ %*+/* +/+,*$%*$+ &/%$/ 4$&/ =$&4/$= $&&%. P$4$ *$+$*$+ %4/ 6$4$ /+$%$+,; ?&*+/ CPR $+, %/+,,/ +/+,*$%*$+ 4/+$/*; 4$+ %$+6$ +/+,*$%*$+ %&$$ (LOE"; S-$&% 1!; M$/& 18!; K&+ 18"). P$4$ $% %$$$+ %4/ 6$4$ /+$%$+,; CPR ?&*+/ %/+,,/ %/4$* +/+,*$%*$+ 4/+$/* // $+, 4/$**$+ CPR %$+4$& (=/% T=*&; 1!).
3.2 K+6 A*6 A. PENGKA>IAN U+$ 4$%$ $+, 4/6& 6$4$ $$% 6+,*$0/$+ $/% 4$%$ 0*%/?; $+%$&$ $/+ : 1. W$&+$ */% 6=$% 2. K/% 4/+,/+ 3. CRT F24%/* !. S/$+/ ** 4$+ //& 5. T&/$% 4/%& 6&+$?$$+ ". T*$+$+ 4$&$ %/4$* $4$ 7. N$4/ 6&/?& %/4$* %&$$
'. DIAGNOSA KEPERAWATAN 1. G$+,,$+ 6&?/ &&$ &+,$+ 4+,$+ 6+&+$+ 6$/ O2 * %$* 2. G$+,,$+ 6&%*$&$+ ,$ &+,$+ 4+,$+ 6$/ O2 %/4$* $4*$% 3. P+&+$+ =&$ 0$+%+, &+,$+ 4+,$+ *$6$+ 66$ 0$+%+, +&+. C. INTERVENSI KEPERAWATAN 1.
G$+,,$+ 6&?/ &&$ &+,$+ 4+,$+ 6+&+$+ 6$/ O2 * %$* $. '&/*$+ $4/$%& /$ +/%&,/&/+;+/?4/6/+ $/ /+4/*$/ . P//*$+ *$*/ / %/+,,/4$&/ 0$+%+, =. P$+%$ $4$+$ 6=$%;/$+/ 4$+ */% 4/+,/+ $%$ $ 4. P$+%$ 6+,//$+ *$6/& (CRT)
2.
G$+,,$+ 6&%*$&$+ ,$ &+,$+ 4+,$+ 6$/ O2 %/4$* $4*
%$ $. '&/*$+ O2 $/ /+4/*$/ . P$+%$ GDA 6$/+ =. P$+%$ 6&+$6$$+ */+ 3.
P+&+$+ =&$ 0$+%+, &+,$+ 4+,$+ *$6$+ 66$ 0$+%+, +&+ $. L$**$+ 6/0$% 0$+%+, . '&/*$+ */,+ %$$$+ 4+,$+ *$+$ +$$$*& 4$+ $% $/ /+4/*$/ =. P$6$/ +$4/ 6&/?& 4. P$+%$ %*$+$+ 4$&$ . K$0/ */% 6=$% 4$+ /$+/
DA9TAR PUSTAKA
D+, M$&/++ E .(2##2). R+=$+$ A$+ K6&$-$%$+ (P4$+ U+%* 4$+ P+4*+%$/$+ P&$-$%$+ P$/+) E4// 3. >$*$&%$ : EGC. S%B&; S. (2##2). '* A0$& K6&$-$%$+ M4/*$ '4$ '&++& S44$&%. V 2 E4// 8. >$*$&%$ : EGC.