ASUHAN KEPERAWATAN PADA KLIEN (CONGESTIVE HEART FAILURE) PENGERTIAN Kegagalan fungsi !"a #an$ung %ala" "en&u'ui 'eu$uan %a*a (nu$*ien$ %an !'sigen) se&a*a a%e'ua$ sesuai %engan 'eu$uan #a*ingan+ ETIOLOGI ,+ Fa'$!* e-$e*na (%a*i lua* #an$ung) . ie*$ensi *enal/ 0e*$i*!i%/ ane"ia '*!nis1 e*a$ 2+ Fa'$!* in$e*na (%a*i %ala"+ #an$ung) a+ Disfungsi 'a$u 3en$*i'ule* se$u" %efe&$ (VSD)/ a$*ial se$u" %efe&$ (ASD)/ s$en!sis1 insuffisiensi "i$*al+ + Dis*i$"ia a$*ial fi*ilasi/3en$*i'el fi*ilasi/3en$*i'el fi*ilasi/ ea*$ l!&'+ l!&'+ &+ Ke*usa'an "0!&a*% is'e"i'1 infa*'/ &a*%i!"0!a$i/ myocarditis / ASHD (A$e*! S&le*!sis Hea*$ Disease)+ %+ Infe'si Sua&u$ 4a&$e*ial En%!&a*%i$is+
MEKANISME KOMPENSASI
,+ Dila$asi 3en$*i'el 2+ Hie*$*!fi 3en$*i'el 5+ Pening'a$an s$i"ulasi sis$e" sa*af si"a$is seingga "ening'a$'an ea*$ *a$e
GE6ALA DAN TANDA GAGAL 6ANTUNG KIRI ,+ V!lu"e %an Te'anan LV 7 LA "ening'a$ 2+ V!lu"e Vena Pul"!nal "ening'a$ 5+ Oe%e"a Pa*u 1 8+ Ca*%ia& Ou$u$ "enu*un seingga e*fusi #a*ingan "enu*un 9+ Da*a 'e *enal %an 'elen#a* "enu*un+ :+ V!lu"e V!lu"e %a*a 'e a*u "enu*un MENYEBABKAN : ,+ Le$a*gi 7 %ia!*esis 2+ D0snea1O*$!nea1PND 5+ Pali$asi (e*%ea*;%ea*) 8+ Ce0ne;S$!'es 9+ 4a$u' (Hae"!$!e) :+ R!n&i asa agian asal a*u+ <+ Te*%enga* Te*%enga* 46 5 7 46 8 1Gall!s *i$"e+ =+ Oligu*ia1anu*ia
GAGAL 6ANTUNG KANAN ,+ V!lu"e Vena sis$e"i' "ening'a$
2+ V!lu"e %ala" !*gan1sel "ening'a$ 5+ Hea* "e"esa* 8+ Lien "e"esa* 9+ Deen%en$ !e%e"a :+ Ha*"!n *e$ensi ai* %an Na> "ening'a$ seingga *eas!*si "ening'a$+ <+ V!lu"e E-$*a Cell Flui%s "ening'a$+ =+ V!lu"e %a*a $!$al "ening'a$ MENYEBABKAN : ,+ Oe%e"a $ung'ai1$u"i$ 2+ CVP "ening'a$ 5+ Pulsasi V+ 6ugula*is 8+ 4en%ungan V+ 6ugula*is16VP "ening'a$ 9+ Dis$ensi a%!"en/ nausea %an an!*e-ia :+ A&i$es <+ 4e*a$ a%an "ening'a$ =+ Hea$!"egali (luna' 7 n0e*i $e'an) ?+ Slen!"egali ,@+ Ins!"nia+
PENGKA6IAN . I+ RIWAAT KEPERAWATAN. ,+ Keluan . Da%a $e*asa e*a$ (see*$i "e"a'ai a#u 'e$a$)/ Pali$asi1e*%ea*;%ea* PND1O*$!nea/ Sesa' nafas saa$ e*a'$i3i$as/ 4a$u' (ae"!$!e)/ Ti%u* a*us a'ai an$al B , ua An!*e-ia/ Nause %an V!"i$ing Le$a*gi ('elesuan) Ins!"nia Ka'i eng'a' %an 44 e*$a"a/ 6u"la u*ine "enu*un Se*angan $i"ul "en%a%a'1se*ing 'a"u+ 2+ Ria0a$ penyakit . ie*$ensi *enal/ angina/ infa*' "0!'a*% '*!nis/ %iae$us "elli$us/ e%a #an$ung/ a*i$"ia+ 5+ A'$ifi$as fisi' . A'$ifBB8+ Ria0a$ %ie$ in$a'e gula/ ga*a"/ le"a'/ 'afein/ &ai*an/ al'!!l+ 9+ Ria0a$ eng!a$an . T!le*ansi !a$/ !a$;!a$ ene'an fungsi #an$ung/ s$e*!i%/ #u"la &ai*an e* IV/ ale*gi+ :+ P!la eli"inasi *e$ensi &ai*an se'un%e*/ n!&$u*ia+ <+ e*!'!'. e*!'!'/ &a*al#u"la a$ang e* an/ #ang'a a'$u+ =+ P!s$u*e/ 'egelisaan/ 'e&e"asan+ ?+ Fa'$!* *e%is!sisi1*esii$asi As$"a/ !esi$as/ penyakit a*u 0ang "e*ua'an fa'$!* en&e$us ening'a$an 'e*#a #an$ung %an "e"e*&ea$ e*'e"angan CHF+
II+ STUDI DIAGNOSTIK ,+ C4C . Ane"ia e*a$ a$au !li&0$e"ia+ W4C . Le'!si$!sis (a%a CI %an myocarditis ) a$au 'ea%aan infe'si lain+ 2+ A4G. "enilai %e*a#a$ gangguan 'esei"angan asa" asa ai' "e$a!li' "auun *esi*a$!*i'+ 5+ F*a'si le"a' . ening'a$an 'a%a* &!les$e*!l1$*iiglise*i% "e*ua'an *esi'! CAD %an enu*unan e*fusi #a*ingan+ 8+ Se*u" 'a$e'!la"in guna "engesa"ing'an penyakit a%*enal+ 9+ Se%i"en$asi . "ening'a$ a'ia$ a%an0a infla"asi a'u$+ :+ T0*!i%. "enilai ening'a$an a'$i3i$as $0*!i% <+ E&!&a*%i!g*a" . "enilai s$en!sis1in&!"e$ensi/ e"esa*an *uang #an$ung/ ie*$*!fi 3en$*i'el+ =+ Ca*%ia& S&an . "enilai un%e*e*fusi!n !$!$ #an$ung/ 0ang "enun#ang enu*unan 'e"a"uan '!n$*a'si+ ?+ R!n$gen $!*a-. un$u' "enilai e"esa*an #an$ung/ !e%e"a a*u+ ,@+ Ka$e$e*isasi #an$ung . "enlai f*a'si e#e'si 3en$*i'el+ ,,+ Ele&$*! Ca*%i!g*ai . "enilai ie*$*!fi a$*iu"13en$*i'el/ is'e"i'/ infa*'/ is*i$"ia+ ,2+ Li3e*1Renal Fun&$i!n Tes$. "enilai efe' 0ang $e*#a%i a'ia$ CHF+ III+ PEERIKSAAN FISIK ,+ E3aluasi s$a$us #an$ung. 44/ T4/ Kele"aan/ $!len*ansi a'$i3i$as/ a*na 'uli$/ !e%e"a/ suu/ na%i e*ife*/PI/ $e'anan %a*a/ un0i #an$ung/ %en0u$ isfe*ien/ gall!s/ "u*"u* (&a*%i!"0!a$i) 2+ Os$*u'$if (I%i!a$i& H0e*$*!i& Su;A!*$i& S$en!sis1IHSS)+ 5+ un&ul %en0u$ 3ena #ugula*is/ 6VPB 9;2 &" ,;,2@/ ulsus al$e*nans/ %isla&e la$e*al PI 0ang "enun#u''an %e&!"ensasi+ 8+ E3aluasi fa'$!* s$*ess. "enilsi ins!"nia/ ening'a$an 3i$al sign/ gugu a$au *asa &e"as1$a'u$ 0ang '*!nis+ 9+ Palasi a%!"en . Hea$!"egali/ slen!"egali/ a&i$es+ :+ Hea$!#ugule* *eflu-+ IV+ PRIORITAS KEPERAWATAN ,+ engu*angi 'e*#a #an$ung %an "ening'a$'an '!n$*a'$ili$as !$!$ #an$ung+ 2+ e"an$u un$u' "enen$u'an en0ea u$a"a+ 5+ e"e*i inf!*"asi $en$ang penyakit / $e*ai/ %an 'e'a"uan+ 8+ e"e*i e*a$ian %an su!*$ si'!l!gis+
V+ ASUHAN KEPERAWATAN KLIEN DECOPENSASI CORDIS %an OEDEA PULONAL Diagn!sa , . Pe*uaan e*fusi #a*ingan 0ang e*uungan %engan enu*unan &u*a #an$ung/ '!nges$i 3ena se'un%e* $e*a%a 'egagalan '!"ensasi #an$ung+ Diagn!sa 2 .
P!$ensial '!"li'asi . s!&' 'a*%i!geni' Da$a enun#ang . S . engelu using/ sesa' nafas/ "ual/ e*'e*inga$ %ingin/ n0e*i %a%a+ O . Hi!$ensi/ $a'i'a*%i/ %is*i$"ia/ %ia!*esis/ ulsus al$e*nans/ 'uli$ %ingin 7 u&a$/ %0snea1!*$!nea1PND/4UN1C*ea$inin "ening'a$/ !ligu*i/ %is$ensi 3ena#ugula*is1 6VPB 5 &" H2@/ *!n&i/ !*$!n!e/ %is*i$"ia/ 46 Ill I IV gall!s/ 46 I a$au II "ele"a a$au sli$/ $e*%enga* "u*"u*1ising+ Tu#uan1sasa*an . Pe*fusi #a*ingan/ &u*a #an$ung 'e"ali n!*"al %an $an%a;$an%a %e&!"ensasi &!*%is e*'u*ang1ilang+ K*i$e*ia1s$an%a* . S . 'eluan %i a$as (a%a %a$a enun#ang) e*'u*ang a$au ilang+ O .Tensi n!*"al %en0u$ na%i 'ua$ f*e'uensi n! *"al 'a%a* 4UN1C*ea$inin n!*"al 6VP B In$e*3ensi . ,+ A$u* !sisi $i%u* 0ang n0a"an (f!le*1ig f!le*)+ 2+ 4e% *es$ $!$al %an "engu*angi a'$i3i$as 0ang "e*angsang $i"uln0a *es!n 3alsa3a+ Ca$a$ *ea'si asien $e*a%a a'$i3i$as 0ang %ila'u'an+ 5+ !ni$!* 3i$al sign %an ai&al ulse se$ia #a" (a%a fase a'u$)/ %an 'e"u%ian $ia 2;8 #a" ila fase a'u$ e*lalu+ 8+ !ni$!* %an &a$a$ $an%a;$an%a %is*i$"ia/ e*uaan un0i #an$ung+ 9+ !ni$!* 4UN1C*ea$inine sesuai *!g*a" $e*ai+ :+ Ose*3asi e*uaan sens!*i <+ Ose*3asi $an%a;$an%a 'e&e"asan %an ua0a'an "e"elia*a ling'ungan 0ang n0a"an+ Ua0a'an a'$u is$i*aa$ %an $i%u* a%e'ua$+ =+ K!la!*asi %engan $ea" gii un$u' "e"e*i'an %ie$ *en%a ga*a"/ *en%a *!$ein/ %an *en%a 'al!*i (ila 'lien !esi$as) se*$a &u'u selul!se+ ?+ 4e*i'an %ie$ se%i'i$;se%i'i$ $ai se*ing %an la'u'an !*al &a*e se&a*a $e*a$u*+ ,@+ La'u'an la$ian ge*a' se&a*a asif (ila fase a'u$ e*lalu) %an $in%a'an lain un$u' "en&ega $*!"!e"!li+ ,,+ K!la!*asi %engan $ea" "e%is un$u' $e*a01$in%a'an . a+ Gli'!si% #an$ung un$u' "ening'a$'an '!n$*a'$ili$as+ + 4an$uan !'sigenasi ($ing'a$'an ali*an1'!nsen$*asin0a) se$ia 'ali 'lien selesai "ela'u'an a'$i3i$as a$au "a'an+ &+ Ce' EKG se*ial %an *!n$gen $!*a- (ila a%a in%i'asi) %+ In!$*!i'+%igi$alis %an 3as!a'$i3e %*ug un$u' "enu*un'an *el!a% %an af$e*l!a%/ "enu*un'an ean 'e*#a #an$ung %an "ening'a$'an CO e+ T*anuilie*1se%a$i3e (ila e*lu)+ f+ An$i e"e$i' %an la-a$i3e un$u' "en&ega a'$i3i$as e*leian 0ang "eni"ul'an *es!n 3alsa3a+ g+ Ka$e$e*isasi #an$ung (Fl!;Di*e&$ Ca$e$e*)/ ila a%a in%i'asi+ + Pasang Pa&e;"a'e* (ila a%a %is*i$"ia "aligna)+ ,2+ !ni$!* se*u" %igi$alis se&a*a e*i!%i'/ %an efe' sa"ing !a$;!a$an se*$a $an%a;$an%a
ening'a$an 'e$egangan #an$ung+ ,5+ 6angan "e"e*i'an %igi$alis ila %i%aa$'an e*uaan %en0u$ na%i1#an$ung/ un0i #an$ung a$au e*'e"angan $!-i&i$as %igi$alis %an sege*a la!*'an 'ea%a $ea" "e%is+ Diagn!sa 5 . Gangguan e*$u'a*an gas 0ang e*uungan %engan a'u"ulasi &ai*an %ala" al3e!li a*u e*leian 3!lu"e &ai*an/ se'un%e* $e*a%a s$a$us e"!%ina"i' $i%a' s$ail Diagn!sa 8 . Resi'! i!'sia e*a$ Da$a Penun#ang . S . sesa' nafas/ &es$ ain/ a$u'/ le$a*gi/ 'ele$ian+ O .agi$asi a$au ingung/ &0an!sis/ !e%e" $ung'ai/ un0i nafas (eeing 1*ales1 *!n&i %i asal a*u)/ *e$*a'si in$e*&!s$ae/ e*nafasan &uing i%ung/ e*uaan nilai A4G (a&i%!sis "e$a!li'1*esi*a$!*i')/ $a&inea1!*$!nea1PND/ 'uli$ 'uning u&a$+ Sasa*an1$u#uan . e"e*$aan'an e*$u'a*an gas %ala" a*u se&a*a a%e'ua$ un$u' "ening'a$'an !'sigenasi #a*ingan+ K*i$e*ia1S$an%a* . S . 'eluan sesa' nafas/ &es$ ain %an a$u' ilang+ O .$an%a &0an!sis 7 !e%e"a $ung'ai ilang un0i nafas n!*"al $an%a $an%a 'e;suli$an e*nafas ilang A4G %ala" a$as n!*"al+ In$e*3ensi . ,+ Ose*3asi un0i nafas/*esi*a$!*0 *a$e %an 'e%ala"an (!la nafas) $ia , J 8 #a"+ 2+ !ni$!* $an%a1ge#ala !e%e"a ul"!nal (sesa' nafas saa$ a'$i3i$as PND1 !*$!nea a$u' $a&0nea su$u" au/ #u"la/ a*na/ '!nsis$ensi un0i nafas *!n&i %i asal a*u ening'a$an Pul"!na*0 A*$e*0 We%ge P*essu*e)+ 5+ P!sisi $i%u* 'lien se"i f!le*+ 8+ 4e% *es$ $!$al %an a$asi a'$i3i$as sela"a e*i!%e sesa' nafas/ an$u "e*ua !sisi (ila e*lu)+ 9+ !ni$!* $an%a1ge#aIa 0!-ia (e*uaan nilai gas %a*a $a&0&a*%ia ening'a$an sis$!li' $e'anan %a*a gelisa/ ingung/ using/ &es$ ain/ &0an!sis %i ii* %an "e"*an "u'!sa)+ :+ e"a$asi #u"la engun#ung+ <+ K!la!*asi %engan $ea" "e%is . a+ Pe"e*ian !'sigen "elalui nasal &anule 8 ; : li$e* 1"eni$ ('e&uali ila 'lien "engala"i 0!-ia '*!nis) 'e"u%ian 2 li$e*1"eni$+ Ose*3asi *ea'si 'lien %an efe' e"e*ian !'sigen (nilai 'a%a* A4G)+ + Te*ai %iu*e$i&/ sule"en$ 'aliu"/ *!n&!%ila$!*/ s!%iu" ni$*!*ussi%e+ &+ S!%iun/ i&a*!na$ (ila a%a in%i'asi) =+ !ni$!* efe' 0ang %ia*a'an/ efe' sa"ing %an $!-i&i$as %an $e*ai 0ang %ie*i'an+ Ce' 'a%a* ele'$*!li$+ ?+ Ose*3asi in$a'e %an !u$u$ &ai*an ($e*u$a"a e* infus) %an $i"ang 44 (ila 'lien $i%a' sesa')+ ,@+ 4a$asi #u"la in$a'e &ai*an e* !*al+
,,+ K!la!*asi %engan $i" gii un$u' "e"e*i'an %ii$ #an$ung (I; IV/ *en%a ga*a"*en%a le"a')+ ,2+ La!*'an 'ea%a $ea" "e%is ila %i%aa$'an $an%a;$an%a $!-i&i$as a$au '!"li'asi 0ang lain+ Diagn!sa 9 . Resi'! $e*a%a 'eleian 3!lu"e &ai*an . e%e"a 0ang e*uungan %engan ening'a$an *el!a%/ enu*unan '!n$*a'$ili$as/ enu*unan ali*an %a*a 'e gin#al/ enu*unan la#u fil$*asi gl!"e*ulus (ening'a$an *!%u'si ADH ) Da$a Penun#ang . S . sesa' nafas/ a$u'/ 'a'i eng'a'/ e*'e*inga$ %ingin+ O. Oe%e"a e-$*e"i$as/44 "ening'a$/%0snea1!*$!nea1PND/A&i$es/ Hea$!"egali/ slen!"egali/ Ca*%i!"egali (*!n$gen$ $!*a- )/ EKG LVH/ RVH/ %e3iasi a-is e*gese*an ae-/ e*uaan %en0u$ na%i/ ening'a$an CVP1PWP14l!!% P*essu*e/ *!n&i/ !ligu*i1anu*ia/ 6VP "ening'a$ B 5 &" H2@/ elea*an 3ena a%!"inal+ Tu#uan1sasa*an . en&ega1"engu*angi1"engilang'an 'eleian 3!lu"e &ai*an %an "ening'a$'an e*fusi #a*ingan+ K*i$e*ia1s$an%a* . S . Keluan e*'u*ang1ilang+ O .CVP/ PWP/ 4P/ %en0u$ na%i1#an$ung/ ::/ l!'asi PI %ala" a$as n!*"al/ !e%e"1 a&i$es e*'u*ang1ilang/ !la nafas n!*"al/ *!n&i ilang1sua*a nafas n!*"al/ Hea* %an Lien n!*"al+ In$e*3ensi . ,+ !ni$!* %an e3aluasi CVP/ PWP/ %en0u$ na%i1#an$ung/4P se&a*a 'e$a$/ $ia #a" (a%a fase a'u$) a$au 2 ;8 #a" se$ela fase a'u$ e*lalu+ 2+ !ni$!* un0i #an$ung/ alasi l!'asi PI %an lea* %en0u$ ae-+ 5+ Ose*3asi $an%a;$an%a *esi*asi &e0ne s$!'es %an %is*i$"ia+ Sege*a la!*'an $i" "e%is/ ila a%a+ 8+ Ose*3asi $an%a;$an%a !e%e"a anasa*'a+ 9+ Ti"ang e*a$ a%an $ia a*i (ila '!n%isi 'lien "e"ung'in'an)+ :+ E3aluasi !la *esi*asi ('e&ea$an/ 'e%ala"an) se*$a un 0i nafas (&a$a$ un0i nafas an!*"al %an enu*unan un0i/ a'u"ulasi su$u") / %0snea/ !*$!nea1 PND/ $a&inea/ a$u'/ fa$igue/ %an ae"!$!e+ <+ Ose*3asi e"esa*an ea* %an lien/ &a$a$ a%an0a nause/ 3!"i$ing/ %is$ensi/ %an '!ns$iasi+ =+ 4a$asi in$a'e &ai*an %an e*i'an %ie$ *en%a ga*a"+ ?+ 4a$asi "a'anan 0ang "eni"ul'an gas %an "inu"an 0ang "engan%ung 'a*!na$+ ,@+ Ose*3asi u*ine !u$u$ e* #a" a$au e* 28 #a"+ ,,+ K!la!*asi %engan $ea" "e%is un$u' $e*ai1$in%a'an. a+ Diu*e$i'/ &a$a$ u*ine !u$u$ %an &e' 'a%a* ele'$*!li$+ + 4*!n&!%ila$!*1A"in!0line (#angan %ie*i'an ila 4P 'lien *en%a)+ &+ O'sigenasi %engan $e'anan *en%a+ %+ T!*a&!&en$esis/ a*a&en$esis/ le!$!"i/ *!$a$ing $!u*niue$ (ila e*lu)+ ,2+ Ose*3asi *ea'si e"e*ian $e*a0
Diagn!sa : . Pe*uaan !la $i%u* 0ang e*uungan %engan n0e*i/ sesa' nafas %an ling'ungan *u"a sa'i$ 0ang asing agi 'lien+ Da$a enun#ang . S . "engelu suli$ $i%u*1se*ing $e*angun/ using/ &es$ ain/ suli$ e*a%a$asi %e;ngan ling'ungan RS/ sesa' nafas+ O ."a$a 'lien sa0u/ a#a $a"a' la0u/ $a"a' Iela 1gelisa1'esa'i$an/ #u"la #a" $i%u* 'lien e*'u*ang/ se*ing "engua1"engg!s!' "a$a/ %0snea1!*$!nea 1PND+ Tu#uan1sasa*an. e"enui 'eu$uan is$i*aa$1 $i%u* 'lien se&a*a a%e'ua$ ('uali$as "auun 'uali$as)+ K*i$e*ia1s$an%a* . S . "enga$a'an "a"u $i%u* %engan n0a"an/ 'eluan;'eluan ilang+ O . #u"la #a" $i%u* n!*"al/ a#a 'lien sega*/ n0e*i1sesa' nafas ilang+
In$e*3ensi . ,+ engi%en$ifi'asi !la n!*"al $i%u* 'i$en seelu" RS %an e*uaan 0ang $e*#a%i se$ela RS+ 2+ e"an$u 'lien %ala" e*a%a$asi %engan Iing'ungan RS+ 5+ enilai a%an0a fa'$!* 0ang "enun#ang $e*#a%in0a gangguan !la $i%u* (sesa' nafas/ PND/ se*ing 'en&ing 'a*ena efe' %iu*e$i'/ n0e*i/ *asa $a'u$/ &e"as/ "e*asa 'eseian/ 'eisingan/ la"u 0ang $e*lalu $e*ang/ $in%a'an e*aa$an)+ 8+ e"e*i'an $in%a'an un$u' "enga$asi fa'$!* en0ea ("enga$u* !sisi $i%u* 0ang n0a"an/ $e*ai %iu*e$i' %ie*i'an a%a agi a*i/ "e"e*i'an !a$ an$i n0e*i sesuai *!g*a" $e*ai/ "e"e*i'an seli"u$/ "e*e%u'an la"u *uangan/ %ll)+ 9+ e"e*i'an $in%a'an e*aa$an seelu" a'$u $i%u* 0ang %aa$ "enun#ang is$i*aa$1$i%u* 'lien ("engg!s!' unggung/ "inu" susu anga$/ g!s!' gigi/ "enga$u* suu *uangan/ "e"e*i'an an$al 0ang n0a"an/ "enga#a' 'lien e*%!a/ %ll)+ :+ e*en&ana'an $in%a'an e*aa$an1"e%is 0ang $i%a' "engganggu #a" is$i*aa$1$i%u* 'ilen+ <+ K!la!*asi %engan $ea" "e%is un$u' e"e*ian !a$ 0ang "e"an$u $i%u* ($*anuilie*) sesuai 'eu$uan1in%i'asi+ Ka#i *ea'si/ efe' sa"ing %an $an%a;$an%a $!-i&i$as (ila a%a/ sege*a la!*'an $ea" "e%is)+ Diagn!sa < . Resi'! $e*a%a 'e*usa'an in$eg*i$as 'uli$ . ul'us %e'ui$us 0ang e*uungan %engan i"!ilisasi1in$!le*ansi a'$i3i$as/!e%e"a %an e*uaan e*fusi #a*ingan+ Da$a enun#ang. S . "engelu unggung $e*asa anas/ an0a' e*'e*inga$/ $i%a' "a"u "ela'u'an a'$i3i$as/ $a'u$ e*ge*a'+ O .Oe%e"a/ e% *es$/ 'uli$ le"a/ %ia!*esis/ "!ili$as asif/ 3i$al sign an!*"al/ alas $i%u* le"a/ 'e"e*aan a%s 'uli$ unggung1%ae*a $e*$e'an lainn0a+
Tuiuan1sasa*an . en&ega 'e*usa'an #a*ingan 'uli$ (ul&us %e'u i$us)+ K*i$e*ia1s$an%a*% . S . 'eluan e*'u*ang1ilang O . Oe%e"a e*'u*ang1ilang/ 'ele"aan 'uli$ n!*"al "a"u "ela'u'an a'$i3i$as sesuai 'e"a"uan/ 3i$al sign %ala" a$as n!*"al/ alas $i%u* e*si %an 'e*ing/ $i%a' $e*%aa$ $an%a e*a%angan a%a unggung a$au %ae*a $e*$e'an+ In$e*3ensi . ,+ Ose*3asi $an%a;$an%a e*a%angan a%a 'uli$ unggung a$au %ae*a 0ang $e*$e'an lainn0a (e*i$e"a %an 'eu&a$an)+ 2+ Guna'an alas $i%u* 0ang le"u$+ 5+ La'u'an e*aa$an 'uli$ %an "assage $ia ais "an%i+ 8+ Gan$i linen ila asa a$au le"a %an '!$!*+ 9+ Gan$i a#u 'lien ila e*'e*inga$ an0a'+ :+ 4an$u "!ilisasi *ingan sesuai 'e"a"uan 'lien %an ua0a'an %aa$ "i*ing 'i*i 1 'anan se$ia 2 #a" se'ali <+ La'u'an e*aa$an %ini %e&ui$us ila %i%aa$'an $an%a 'e"e*aan a%a 'uli$ 0ang $e*$e'an+ =+ Te$a'an #a%al eng!s!ngan 'an%ung 'e"i ("ulai %engan se$ia 2 #a")
