LAPORAN RESUME ASUHAN KEPERAWATAN PADA PASIEN Tn. E.S DENGAN DIAGNOSA FRAKTUR KRURIS TERBUKA DI RUANGAN IGD, RSUP. HASAN SADIKIN BANDUNG
I. PENGKAJIAN A. B!"#$# 1. I"%n$$#& K'%n N#(# U()* %n& K%'#(n A#(# S)) P%n""#n P%%*##n A'#(#$ T'. M#&) RS T'. P%n##n N!. RM
: Tn. E S : 21 + + 1--2 23 $#/)n : L# +'# : I&'#( : S)n"# : SMA : S&4# : R#n# %n% : 26 + 10 + 2015 : 26 + 10 + 2015 : 0001
2. I"%n$$#& 7%n#n)n #4#8 N#(# : N9. A H)8)n#n : I8) K'%n B. SURVEY PRIMER 1. A*4#9 A; T"# #"# &)(8#$#n 7#"# #'#n n#<#&, $"# #"# 7%n)(7)#n &%*%$, $"# #"# 7%*"#*#/#n 7#"# /")n. S)#*# n#<#& =%&)'%*, $"# #"# &)#*# n#<#& $#(8#/#n.
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T"# #"# "&$%n& #8"!(%n, 8&n )&)& n!*(#', $"# #"# n9%* $%#n. S&$%( )*!%n$#' T"# #"# n9%* $%#n 7#"# 8##n '%$# n#', #*%# %n$#'# $"# " # S&$%( n%)*!'!& G>S ? 15, E ? , M ? @, V ? 5; %&#"#*#n !(7!&(%n$& S&$%( ()&)'!&%'%$#' P#"# %&$*%($#& #$#& $"# #"# %'#n#n, ROM 8%8#&, $"# #"# n9%* $%#n, "#n 7#"# %&$*%($#& 8#4#/ $%*"#7#$ <*#$)* $%*8)# 7#"# # * " '!#& $8# <8)'#, $%*"#7#$ 7%*"#*#/#n #$<. S&$%( n$%)(%n A*#' "nn, $)*!* )'$ 8#, )'$ '%(8#8.
2. F')", F#*#n/%$ F; T%*#8# "nn, $"# #"# %"%(#, ()!&# 88* '%(8#8. 3. G%$ V$#' Sn G; TD ? 120-0 N ? 0 (n$ S ? 3@,0 R ? 2 (n$ . H%#" T! T!%, H&$!*9 H; K%7#'# •
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E&$*%($#& P#"# %&$*%($#& #$#& $"# #"# <*#$)*, ROM 8%8#&, %)#$#n !$!$ 55, 7#"# %&$*%($#& 8#4#/ $%*"#7#$ <*#$)* $%*8)# 8##n $8# <8)'# &n&$*# "%n#n 7%*"#*#/#n #$<, ROM $%*8#$#&, %)#$#n !$!$ $"# $%*#. T"# #"# %"%(# 7#"# %&$*%($#& #$#& "#n 8#4#/.
H&$!*9 H; K%')/#n )$#(# : • N9%* 7#"# ')# R4#9#$ %')/#n )$#(# : • K'%n (%n#$##n #$)/ "#* 7!/!n 7#"# #(
[email protected] 48, '%n (%n#$##n $%*%'n* &##$ &#'#/ (%nn# *#n$n 7!/!n, '%n (%n#$##n (%*#&# # *n9# $"# 8&# " %*##n "#n $%*#&# &#$. K%()"#n '%n " 8#4# % 7)&%&(#& R#n# %n% )n$) 7%*$!'!n#n 7%*$#(# '#') " *)) % *)(#/ &#$ (##'%n#. L#') " *)) % RSHS )n$) 7%n#n#n#n '%8/ '#n)$. S##$ " # '%n (%n%')/ n9%* 7#"# ')#n9#, '%n $#(7# (%*n&, &#'# n9%* 6 8%*#$; NRS 0 + 10;. 5. In&7%$ T/% P!&$%* I; K%#"##n )'$ 7)n)n 8#, $"# $%*#" %(%*#/#n D. DATA PSIKO – SOSIAL – SPIRITUAL
DO : −
−
−
2. 26 + 10 2015
T#(7# <*#$)* $%*8)# 7#"# $8# <8)'# &n&$*# T#(7# 7%*"#*#/#n #$< 7#"# ')# K'%n $#(7# (%*n&
DS : DO :
T#(7# 7%*"#*#/#n #$< K!n)n$=# #n%(& M)!&# 88* %*n
III.
PRIORITAS MASALAH 1. N9%*
K%*)&##n #*n#n ')n# K%*)&##n &#*#<, &7#&(% !$!$ N9%* " 7*%&%7&#n T*#)(# '#n&)n 7#"# # K%*)&##n =#&)'#* K%*)&##n #*$%* "#n 8#n9# "#*#/ 9#n /'#n R%&! &9!
R%&! &9! /7!=!'%(
V.
RENCANA KEPERAWATAN
NO.
DIAGNOSA KEPERAWATAN
1.
N9%* 8%*/)8)n #n "%n#n !(7*%& &#*#<, 7%*%*##n <*#(%n $)'#n. D$#n"# "%n#n : DS : −
K'%n (%n#$##n n%* 7#"#
−
')#n9# K'%n (%n#$##n #$)/ "#*
7!/!n #*%n# &#'#/ (%nn# *#n$n 7!/!n DO : −
T#(7# <*#$)* $%*8)# 7#"#
−
$8# <8)'# &n&$*# T#(7# 7%*"#*#/#n #$<
−
RENCANA TUJUAN INTERVENSI S%$%'#/ "'#)#n 1. K# &#'# n9%* $n"##n %7%*#4#$#n &%'#(# 1 2 #(, " /#*#7#n n9%* 8%*)*#n. D%n#n *$%*# /#&' : 1. K'%n (%n#$##n 2. P#n$#) %')/#n n9%* n9%* 8%*)*#n '!#', #7##/ #"# 2. K'%n $"# (%*n& 7%(8%n##n 3. S#'# n9%* 8%*)*#n 3. A$)* 7!&& (!8'&#& NRS 0 + 10; 7#"# $)n# 8#4#/
7#"# ')# K'%n $#(7# (%*n& . L#)#n 7%(#&#n#n 7&
RASIONAL 1. N9%* (%*)7##n *%&7!n& &)8%$< 9#n "#7#$ "# "%n#n (%n)n##n &#'# n9%*.
PARAF
2. D%$%& "n )n$) (%n%$#/) #"#n9# $#n"# &n"*!( !(7#*$%(%n 3. I(!8'&#& 9#n #"%)#$ "#7#$ (%n)*#n 7%*%*##n <*#(%n $)'#n 9#n (%n#" )n&)* )$#(# 7%n9%8#8 n9%* $)n# 8#4#/. . G7& 7#&# 8%"#/ ")n##n 7%*%*##n <*#(%n $)'#n 9#n (#&/ '%(#/ 9#n (%*)7##n 7*%"&7!&& &$()')& n9%*
PPN 14 STIK IMMANUEL
5. B%*#n 'n)n#n $%n#n
@. A#*#n $%/n *%'#&#& n#7#& "#'#( %$# n9%* ()n)'
6. K!'#8!*#& 7%(8%*#n #n#'%& 2.
R%& ! & 9! /7!=!' %( 8%*/)8)n#n "%n#n /'#nn9# "#*#/ "#* ')# $%*8)#. D$#n"# "%n#n : DS : DO : T#(7# 7%*"#*#/#n #$< K!n)n$=# #n%(& M)!&# 88* %*n
S%$%'#/ "'#)#n $n"##n %7%*#4#$#n &%'#(# 1 2 #(, "/#*#7#n &9! $"# $%*#". D%n#n *$%*# /#&' : 1. K'%n $"# (%n%')/ 7)&n 2. M%(8*#n ()!&# '%(8#8 3. T)*!* )'$ n!*(#' . >RT 3 "%$
1. K# %/'#n#n #*#n
2. A)&)'$#& TD 8#n"n#n %")# '%%n#n
5. Ln)n#n $%n#n ##n (%n)*)n#n &$()')& n9%* %&$%*n#'. @. M%nn#$#n #&)7#n !&%n &%/n# ##n (%n)*)n#n n9%* &%)n"%* #8#$ &%(. 6. An#'%& (%(8'! 'n$#&#n n9%* &%/n# n9%* ##n 8%*)*#n 1. K%/'#n#n #*#n "#7#$ 8%*#&#' "#* <#$!* n#' "#n "')#* n#'. 7%n9#$ 9#n (%n"#&#* $%*#"n9# %)*#n#n =!')(% #*#n n )# /#*)& "#$#&. P%*"#*#/#n /#*)& "%n"#'#n. 2. H7!$%n& "#7#$# $%*#" 7#"# /7!=!'%(# 9#n (%n)n)#n $%*'8#$n9# &&$%( #*"!=#&)'%* )n$)
PPN 14 STIK IMMANUEL
3. K# 4#*n# )'$, &)/), &#n!&&, n#" 7%*<%*, "#n "#
(%'#)#n !(7%n&#& (%(7%*$#/#n#n $%#n#n "#*#/ 3. M%n%$#/) #"#n9# 7%n#*)/ 7%*n#$#n $#/#n#n 7%*<%*
. P%*)8#/#n <*%)%n& "#n *#(# #n$)n (%n)n)#n !(7'#& "&*$(# 5.
5. K!'#8!*#&: 7%*$#/#n#n 7%(8%*#n #*#n (%'#') n$%*=%n#
#')* 9#n 7#'n )n$) 7%(8%*#n #*#n %7#$ "#n (%()"#/#n 7%*#4#$ "#'#( (%'#)#n !n$*!' #&)7#n "#n &#')*#n #*#n.
PPN 14 STIK IMMANUEL
VI.
CATATAN PERKEMBANGAN No . D X 1.
T! " J#$ 26 + 10 + 2015 15.00 15.00 15.10 15.15 15.15
2.
26 + 10 + 2015 15.00 15.00 15.15
I$%!&$&'(#)* " R&)%o'
N#$#/P#+#,
1. M%n# &#'# n9%* "%n#n /#&' '%n (%n#$##n n9%*n9# #"# " &#'# 6 8%*#$; NRS 0 + 10;. 2. M%(#n$#) %')/#n n9%* '!#', #7##/ #"# 7%(8%n##n "%n#n /#&' '%n (%n%')/ n9%* 7#"# ')#n9# "#n $"# #"# 7%(8%n##n. 3. M%n#$)* 7!&& (!8'&#& 7#"# $)n# 8#4#/ "%n#n /#&' '%n "7#&#n 8"# 7#"# '!#& <*#$)*. 5. M%(8%*#n 'n)n#n $%n#n "%n#n /#&' "8#$#& 7%n)n)n @. M%n##*#n $%/n *%'#&#& n#7#& "#'#( %$# n9%* ()n)' "%n#n /#&' '%n (%'#)#n $%/n *%'#&#& &##$ n9%* $(8)'.
1. M%n# %/'#n#n #*#n "%n#n /#&' #"# <*#$)* $%*8)# "%n#n 7%*"#*#/#n " 8##n ')#. 3. M%n# 4#*n# )'$, &)/), &#n!&&, n#" 7%*<%*, "#n "#
PPN 14 STIK IMMANUEL
