LAPORAN PENDAHULUAN ASUHAN KEPERAWATAN PADA KLIEN DENGAN GANGGUAN KEBUTUHAN RASA AMAN DAN NYAMAN (NYERI) RUANG NAKULA I RSUD K.R.M.T WONGSONEGORO SEMARANG Disusun untuk memenuhi tugas tugas Praktek Belajar Klinik Keperawatan Dasar Profesi
Oleh: SILVIA RAHMAWATI P1337420916029
PROGRAM STUDI PROFESI NERS SEMARANG JURUSAN KEPERAWATAN SEMARANG POLITEKNIK KESEHATAN KEMENKES SEMARANG 2017
A. Pene!"#$n
1. Kenyamanan Kenyamanan aalah !"a#" $eaaan #elah #e%&en"h'nya $e("#"han a!a% man"!'a yan) mel'&"#' $e("#"han $e#en#%aman *!e%#a $e&"a!an yan) men'n)$a#$an &enam&'lan !eha%'+ha%', $ele)aan *$e("#"han #elah #e%&en"h'an #%an!enen *$eaaan #en#an) !e!"a#" yan) mele('h' ma!alah a#a" nye%',. 2. ye%' ye%' me%"&a$an &en)alaman !en!/%' an em/!'/nal yan) #'a$ menyenan)$an yan) m"n"l a$'(a# $e%"!a$an a%'n)an yan) a$#"al a#a" &/#en!'al a#a" ')am(a%$an alam hal $e%"!a$an !eem'$'an %"&a *AA- 2011,. ye%' #e%a' (e%!ama (anya$ &%/!e! &enya$'# a#a" (e%!amaan en)an (e(e%a&a &eme%'$!aan 'a)n/!#'$ a#a" &en)/(a#an. ye%' !an)a# men))an))" an meny"l'#$an le('h (anya$ /%an) '(an'n) !"a#" &enya$'# mana&"n. Seh'n))a !e!e/%an) yan) men)alam' nye%' a$an me%a!a #e%)an))" $enyamanan. ye%' 'e'n'!'$an !e(a)a' !"a#" $eaaan yan) mem&en)a%"h' !e!e/%an) an e$!#en!'nya '$e#ah"' ('la !e!e/%an) &e%nah men)alam'nya *Tam!"%'- 2007,. Pem(a)'an nye%' (e%a!a%$an #'&enya: a.
ye%' a$"# !e(a)a' $"m&"lan &en)alaman yan) #'a$ menyenan)$an- #e%$a'# en)an !en!/%'- &e%!e&!' an em/!' !e%#a (e%$a'#an en)an %e!&/n a"#/n/m'$- &!'$/l/)'$- em/!'/nal an &e%'la$". Hal 'n' (e%$a'#an en)an &enya$'# a$"#- /&e%a!' a#a" &%/!e"% &en)/(a#an.ye%' a$"# ('a!anya &e%'!#'a (a%" an #e%a' !ea%a #'(a+ #'(a- (e%lan)!"n) !'n)$a# ya'#" $"%an) a%' 6 ("lan.
(.
ye%'
$%/n'!
aalah
!'#"a!'
a#a"
$eaaan
&en)alaman nye%' yan) mene#a& !elama (e(e%a&a ("lan5#ah"n *le('h a%' 6 ("lan, !e#elah a%' !"a#" a!e &enyem("han a%' !"a#" &enya$'# a$"# a#a" 'n"%'. B. E"#%&%# a. T%a"ma 1, Me$an'$ ye%' #'m("l a$'(a# ""n)+""n) !a%a (e(a! men)alam' $e%"!a$an-
m'!alnya a$'(a# (en#"%an l"$a.
2, The%m'! ye%' $a%ena ""n) !a%a %e!e&#/% mena&a# %an)!an) a$'(a# &ana!'n)'n- m'!al $a%ena a&' an a'%. 3, Khem'! T'm("l $a%ena a%' a# $'m'a yan) (e%a!al a%' a!am a#a" (a!a $"a#. 4, le$#%'$ T'm("l $a%ena &en)a%"h al'%an l'!#%'$ yan) men)ena' %e!e&#/% %a!a nye%' yan) men'm("l$an $e$ean)an /#/# an l"$a (a$a%. (. e/&la!ma 1, 8'na$ 2, ana! . Pe%aan)an ye%' $a%ena $e%"!a$an ""n)+""n) !a%a %e!e&#/%
a$'(a# aanya
&e%aan)an a#a" #e%e&'# /leh &em(en)$a$an /n#/h a(!e!. . an))"an !'%$"la!' a%ah an $ela'nan &em("l"h a%ah. e. T%a"ma &!'$/l/)'. '. F$"%! Pene"*+ ye%' a&a# #'m("l a$'(a# $/n'!'+$/n'!' !e&e%#' '(aah 'n': 1. S#'m"la!' K'm'a *H'!#am'n- (%a'$'n'n- &%/!#a)lan'n- (e%maam+maam
2. 3. 4. . 6. 7.
a!am, Pem(en)$a$an 8a%'n)an S&a!m"! O#/# Keham'lan Inlama!' Kele#'han Kan$e%
D. P$"%,#+#%&%# Aanya !#'m"l"! yan) men)ena' #"("h *me$an'$- #e%mal- $'m'a, a$an
menye(a($an &ele&a!an !"(!#an!' $'m'a !e&e%#' h'!#am'n- (%a'$'n'n- $al'"m. S"(!#an!' #e%!e("# menye(a($an n/!'!e&#/% (e%ea$!'- a&a('la n/!'!e&#/% mena&a' am(an) nye%'- ma$a a$an #'m("l 'm&"l! !ya%a yan) a$an '(aa /leh !e%a("# !a%a &e%'e%. Se%a("# !ya%a &e%'e% yan) a$an mem(aa 'm&"l! !ya%a aa "a en'!- ya'#" !e%a("# A+el#a yan) (e%m'el'na!' an !e%a("# ; yan) #'a$ (e%m'el'na!' an (e%"$"%an !an)a# $e'l !e%#a lam(a#. 'm&"l! !ya%a a$an ' (aa !e&anan) !e%a("# !ya%a !am&a' $e $/%n"! /%!al'! me"lla !&'nal'!. Im&"l! !ya%a #e%!e("# a$an menye(a($an $/%n"! /%!al'! mele&a!$an ne"%/#%a!m'#e% *!"(!#an!' P,. S"(!#an!' P 'n' menye(a($an #%an!m'!' !'na&!'!
a%' !a%a &e%'e% $e !a%a #%a$#"! !&'n/#alam"!. Hal 'n' mem"n)$'n$an 'm&"l! nye%' '#%an!m'!'$an le('h a"h $e alam !'!#em !a%a &"!a#. Se#elah 'm&"l! !ya%a !am&a' ' /#a$- /#a$ men)/lah 'm&"l! !ya%a $em"'an a$an #'m("l %e!&/n %ele$ &%/#e$#' *P/##e% an Pe%%y-2006,. E. T$n-$ -$n Ge$&$ Tana an )eala nye%' yan) "m"m #e%a' an#a%a la'n: 1. an))"am T'"% 2. P/!'!' Men)h'na%' ye%' 3. e%a$an Men)h'na%' ye%' 4. P"a# . Pe%"(ahan a!" Ma$an
Re!&/n &e%'la$" #e%haa& nye%' a&a# mena$"&: 1. Pe%nya#aan
/$"! &aa a$#'<'#a! men)h'lan)$an nye%', . In'<'" yan) men)alam' nye%' en)an a'#an menaa$ a&a# (e%ea$!' !an)a# (e%(ea #e%haa& nye%' yan) (e%lan)!"n) !elama (e(e%a&a men'# a#a" mena' $%/n'!. ye%' a&a# menye(a($an $ele#'han an mem("a# 'n'<'" #e%lal" le#'h "n#"$ me%'n#'h a#a" menan)'!. Pa!'en a&a# #'"% (ah$an en)an nye%' he(a#. Pa!'en a&a# #am&a$ %'le$! an #e%l'(a# alam a$#'<'#a! $a%ena mena' mah'% alam men)al'h$an &e%ha#'an #e%haa& nye%'. F. Peme%'$!aan Pen"nan) 1. Peme%'$!aan >'!'$ In!&e$!' ' a%ea nye%' Pal&a!' en)an mene$an !ea%a &elan an !'!#ema#'$- %a(a ae%ah nye%' yan) &al'n) %'n)an "l"- /(!e%
Peme%'$!aan ne"%/l/)'! Peme%'$!aan m/#/%'$ : en)an men))"na$an %ele$! &a#ella Peme%'$!aan !en!/%'$ : %a!a %a(a- !a$'#- !"h"- )e#a% Peme%'$!aan ROM
a&a# 'la$"$an "n#"$ mem&e%$'%a$an e%aa# nye%'- aa #'a$ &enye(a( nye%' 6. Peme%'$!aan la(/%a#/%'"m Mel'&"#'
: &eme%'$!aan
ae%ah
%"#'n-
&eme%'$!aan
"%'n %"#'n-
&eme%'$!aan $'m'a a%ah- &eme%'$!aan !e%/l/)'. 7. Peme%'$!aan %a'a)n/!#'$ *@+/#/ #"lan) (ela$an)- @+/#/ $e&ala !(, . Peme%'$!aan &en"nan) yan) la'n "l#%a!/n/)%a'- /#/ %/n#)en 9. Mela$"$an &en)"$"%an !$ala nye%'
Ke"e!$n$n /
0
: T'a$ nye%'
1+3
: ye%' %'n)an- !ea%a /(ye$#' $l'en a&a# (e%$/m"n'$a!' en)an (a'$.
4+6
: ye%' !ean)- !ea%a /(ye$#' $l'en mene!'!- a&a# men"n"$an l/$a!' nye%'- a&a# mene!$%'&!'$annya- a&a# men)'$"#' &e%'n#ah en)an (a'$.
7+9 : ye%' (e%a#- !ea%a /(ye$#' $l'en #e%$aan) #'a$ a&a# men)'$"#' &e%'n#ah #a&' ma!'h %e!&/n #e%haa& #'na$an- a&a# men"n"$$an l/$a!' nye%'- #'a$ a&a# mene!$%'&!'$annya- #'a$ a&a# 'a#a!' en)an al'h &/!'!' naa! &anan) an '!#%a$!' 10
: ye%' !an)a# (e%a#- &a!'en !"ah #'a$ mam&" la)'
G. P$"$ ele$#%'$
ne/&la!ma
$hem'$
me$an'!
#%a"ma
#he%m'!
&e%aan)an
T%a"ma &!'$/l/)'!
S"(!#an!' $'m'a le&a! *h'!#am'ne- (%a'$'n'n an $al'"m,
/!'!e&#/% mele&a!$an 'm "l! B+el#a an ; $/%n"! /%!al'! me"lla men)el"a%$an !"(!#an!' P Im&"l! !am&a' $e SSP '
Re!e&#/% nye%'
Sa%a m/#/%'$ Re!&/n nye%'
P/!'!' men)h'na%' nye%'
Ne!#
Pa!'en me%a!a$an !a$'# a&a('la mela$"$an el'm'na!'
Pa!'en men)a#a$an #a$"# "n#"$ el'm'na!' an #'a$ ma" "n#"$ el'm'na!' De,#+#" Pe!$$"$n D#!#/ E#n$+#
(S*34e! / I!$n5 2012) H. Pen$#$n 1. Pen$#$n U3*3 a. Ien#'#a! &a!'en *nama- "m"%- en'! $elam'n- &e$e%aan- alama#- an la'n+
la'n, (. R'aya# $e!eha#an mel'&"#' : 1, Kel"han "#ama $el"han yan) '%a!a$an &a!'en &aa !aa# &en)$a'an. Pa!'en a&a# a#an) hanya en)an $el"han nye%' a$'(a# #%a"ma. 2, R'aya# &enya$'# !e$a%an) Pen)$a'an %'aya# &a!'en !aa# 'n' mel'&"#' ala!an &a!'en yan) menye(a($an #e%a' $el"han5)an))"an %a!a nyaman: nye%' a$"# &aa $l'en. 3, R'aya# &enya$'# ah"l" Pen)$a'an %'aya# &enya$'# ' ma!a lal" yan) (e%h"("n)an en)an &emen"han $e("#"han %a!a nyaman: nye%' a$"#. 4, R'aya# &enya$'# $el"a%)a Pen)$a'an %'aya# &enya$'# $el"a%)a- m'!alnya #en#an) aa a#a" #'a$nya %'aya# ale%)'- !#%/$e- &enya$'# an#"n)- 'a(e#e! mel'#"!. . P/la $e!eha#an "n)!'/nal 1, Pe%!e&!' an meneemen $e!eha#an Mel'&"#' $e('a!aan h'"& $l'en !e&e%#' &en))"naan /(a# !#e%/' yan) a&a# men))an))" me#a(/l'!me $al!'"m- &en)$/n!"m!'an al$/h/l yan) ('!a men))an))" $e!e'm(an)annya an a&a$ah $l'en mela$"$an /lah%a)a a#a" #'a$. 2, "#%'!' me#a(/l'$
m"!$"l/!$ele#al #e%"#ama &aa lan!'a. Sela'n '#" ")a /(e!'#a! ")a men)ham(a# e)ene%a!' an m/('l'#a! $l'en.
3, P/la el'm'na!' Ka' %e$"en!'- $/n!'!#en!'- a%na !e%#a (a" ee! &aa &/la el'm'na!' e$al.
Sean)$an
&aa
&/la
el'm'na!'
"%'n
'$a'
%e$"en!'-
$e&e$a#annya- a%na- (a"- an "mlah. Paa $e"a &/la 'n' ")a '$a' aa $e!"l'#an a#a" #'a$. 4, P/la '!#'%aha# #'"% Pen)$a'an 'la$!ana$an &aa lamanya #'"%- !"a!ana l'n)$"n)an$e('a!aan #'"%- an $e!"l'#an #'"% !e%#a &en))"naan /(a# #'"%. , P/la a$#'<'#a! Ka%ena #'m("lnya nye%'- $e#e%(a#a!an )e%a$- ma$a !em"a (en#"$ $e)'a#an $l'en mena' (e%$"%an) an $e("#"han $l'en &e%l" (anya$ '(an#" /leh /%an) la'n. Hal la'n yan) &e%l" '$a' aalah (en#"$ a$#'<'#a! $l'en #e%"#ama &e$e%aan $l'en 6, P/la &e%!e&!' $/)n'#' Kl'en (e%'!'$/ %a!a ema!- %a!a $e#'a$mam&"an "n#"$ mela$"$an a$#'<'#a! !ea%a /&#'mal- an &anan)an #e%haa& '%'nya yan) !alah *)an))"an (/y 'ma)e,. 7, P/la $/n!e& '%' Kl'en mem&"nya' 'en#'#a! '%' yan) 'an"#nya- (a'$ ' alam $el"a%)a an !a"a%a ")a ' alam ma!ya%a$a#. A&a yan) ''n)'n$annya mena' $/n!e& '%' alam h'"&nya. , P/la &e%an an h"("n)an Kl'en a$an $eh'lan)an &e%an alam $el"a%)a an alam ma!ya%a$a#. Ka%ena $l'en ha%"! menalan' %aa# 'na&. 9, P/la %e&%/"$!' an !e$!"al Mel'&"#' a$#'<'#a! !e$!"al $l'en an &/la %e&%/"$!'nya mel'&"#' &e%enanaan "n#"$ mem&"nya' ana$ a#a" $e#"%"nan an $e&"#"!an "n#"$ men'$ah an mem&"nya' ana$ (e%a&a. 10, P/la &e%#ahanan '%' an $/&'n) Me$an'!me a#a" a%a yan) 'la$"$an $l'en alam men)a#a!' (e%(a)a' ma!alah alam h'"&nya- (a'$ $/&'n) $/n!#%"$#' ma"&"n $/&'n) e!#%"$'#. 11, Keya$'nan an !'!#em n'la' Te%$a'# a)ama an $e&e%ayaan yan) 'an"# $l'en- !e%#a "!aha $l'en "n#"$ #e#a& mela$"$an a$#'<'#a! !&'%'#"alnya !elama !eha# ma"&"n !a$'#.
. Peme%'$!aan '!'$ Peme%'$!aan '!'$ 'la$"$an en)an a%a 'n!&e$!'- &al&a!'- a"!$"l#a!'- an &e%$"!'. >/$"! &eme%'$!aan '#""$an $e&aa ae%ah yan) men)alam' )an))"an.
Peme%'$!aan
mel'&"#'
$e!aa%an-
#ana+#ana
<'#al
an
&eme%'$!aan head to toe. e. Peme%'$!aan &en"nan). Peme%'$!aan yan) 'la$"$an "n#"$ men"$"n) '#e)a$$annya 'a)n/!a me'! ma"&"n 'a)n/!a $e&e%aa#an !elama $l'en '%aa# ' &elayanan $e!eha#an yan) a$an mem(e%'$an 'n/%ma!' yan) ela! #e%$a'# $ela'nan yan) aa &aa $l'en.
I.
ANALISA DATA NO TGL
DATA a#a S"(e$#'
Pa!'en
PROBLEM : ye%' A$"#
men)a#a$an
me%a!a$an !a$'# an nye%'
&aa
(a)'an
&/!#
/&e%a!'
'
an"!nya
yan)
men)alam' hem/%/'. P: Kl'en men)a#a$an !a$'#
an nye%' '
(a)'an &/!# /&e%a!' (a)'an an"!nya yan) men)alam' hem/%/'. Mena' le('h ("%"$ a&a('la (e%)e%a$. C:
ye%'
yan)
'%a!a$an !e&e%#' ' #"!"$+#"!"$. R:
ye%'
#'a$
menala% $e (a)'an #"("h
la'n-
nye%'
ETIOLOGI A)en ;ee%a >'!'$
#e$an *D,. S : S$ala nye%' . T:
ye%'
yan)
'%a!a$an
#e%"!
mene%"!. Kl'enmen)a#a$an ma!'h
nye%'
#e%l'ha#
an
menahan
nye%'
a#a
O(e$#'
Keaaan
:
"m"m
*"$"&,- nye%' !$ala - $e!aa%an */m&/! men#'!,- $l'en #e%l'ha# menahan
me%'n)'!
menahan nye%'- nye%' #e$an *D,. Te$anan a%ah: 110570 mmH) a': 2
2
@5men'#-
17 A&%'l
S"h": 36-4 /;. a#a S"(ye$#'
2012
Pa!'en #a$"# $a%ena /&e%a!'
: e'!'#
men)a#a$an Pe%aa#an "n#"$
EAE
l"$a
&/!#
hem/%/'
yan) aa ' an"!nya#a$"#
EAE
nye%'
$a%ena yan)
'%a!a$annya.
a#a
O(ye$#':
'%': l'm'na!'
Pen"%"nan m/#'
Te%l'ha#
l"$a
/&e%a!'
&/!#
hem/%/'
yan) aa ' an"!nya &e%"# $e%a!
&a!'en
#e%a!a
('la'#e$an-
&a!'en (el"m &e%nah EAE !ea$ #an))al 16 A&%'l 2012. J.
DIAGNOSA KEPERAWATAN
1.
ye%' a$"# (e%h"("n)an en)an a)en ee%a '!'$.
2.
e'!'# &e%aa#an '%': el'm'na!' (e%h"("n)an en)an &en"%"nan m/#'
K. Ren$n$ A+*$n Ke6e!$$"$n T&J$3
N%. DP 1
T**$n In"e!8en+# Se#elah 'la$"$an #'na$an $e&e%aa#an !elama 1. Pe34e!#$n An$&e"#
3@24
am
'ha%a&$an
nye%'
a$"#
a&a# a. Ten#"$an l/$a!' nye%'- $a%a$#e%'!#'$- $"al'#a!- an
(e%$"%an)5#e%$/n#%/l- en)an $%'#e%'a ha!'l:
(e%a# nye%' !e(el"m mem(e%'$an &en)/(a#an.
1. T#n$" en$3$n$n5 en)an 'n'$a#/%:
(. ;e$ a#a#an me'! "n#"$ en'! /(a# /!'!- an
In'$a#/% 1 2 3
T""an Mela&/%$an
$e&"a!an
en)an $/n#%/l )eala Men)e$!&%e!'$an $e&"a!an
ha#'
en)an
%e$"en!' &em(e%'an anal)e#'$. 4
@
ha#'
.
@
yan) a$an ')"na$an. e. M/n'#/%
l'n)$"n)an '!'$ Men)e$!&%e!'$an $e&"a!an
. Ka' aanya ale%)' /(a#.
#ana <'#al
!e(el"m
an
!e!"ah
&em(e%'an anal)e#'$ na%$/#'$ !aa# &e%#ama $al' en)an
@
h"("n)an !/!'al Men)e$!&%e!'$an $e&"a!an en)an $/n#%/l
a#a" '$a m"n"l #ana yan) #'a$ ('a!anya. . Ee%'$an anal)e#'$ !e!"a' am &em(e%'an.
@
nye%' Ke# : !$ala 1 *#'a$ ae$"a#,- 2 * !e'$'# ae$"a#,- 3 *m/e%a# ae$"a#,- 4 *!"(!#an!' ae$"a#,- *#/#al
). /$"men#a!'$an %e!&/n anal)e#'$ an ee$ yan) m"n"l.
ae$"a#,.
2. K%n"!%& ne!#5 en)an 'n'$a#/%:
In'$a#/% 1 2 3
T""an Men)enal &enye(a( nye%' Men)enal
/n! e#
nye%' Men))"na$an anal)e#'$ yan) #e&a# Men)enal #ana+ #ana &ene#"! nye%' "n#"$
mena%'
&e%#/l/n)an Men)enal
)eala
nye%' Mela&/%$an
$/n#%/l
4
@
2. M$n$e3en Ne!#
a. Ka'
!ea%a
$/m&%ehen!'
#en#an)
nye%'-
mel'&"#': l/$a!'- $a%a$#e%'!#'$ an /n!e#- "%a!'@ @
@
%e$"en!'- $"al'#a!- 'n#en!'#a!5(e%a#nya nye%'- an a$#/%+a$#/% &%e!'&'#a!'. (. Ee%'$an anal)e#'$ !e!"a' en)an an"%an. . "na$an $/m"n'$a!' #e%a&e"#'$ a)a% &a!'en a&a# men)e$!&%e!'$an nye%'. . An"%$an &a!'en "n#"$ mem/n'#/% !en'%' nye%'. e. Aa%$an &en))"naan #e$n'$ n/n+a%ma$/l/)' *e@:
@
%ela$!a!'
naa!
alam-
#e%a&'
m"!'$-
'!#%a$!'- ma!!a!e- )"'e 'ma)e%y ll,. .
nye%'. @ nye%' ). M/ ''$a!' #'na$an men)/n #%/l nye%' Ke# : !$ala 1 *#'a$ ae$"a#,- 2 * !e'$'# ae$"a#,- 3 (e%a!a%$an %e!&/n &a!'en. *m/e%a# ae$"a#,- 4 *!"(!#an!' ae$"a#,- *#/#al h. T'n)$a#$an #'"%5'!#'%aha# yan) "$"&. '. M/n '#/% $en yamanan &a!'en #e%haa&
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DAFTAR PUSTAKA
Ee%man- A"%ey. *2009,. Buku Ajar Praktik Keperawatan Klinis Kozier and Erb’s Techniues in !linical "ursing#8a$a%#a: ; ;a%&en'#/- Lyna"all. *199,. Diagnosa Keperawatan $ Aplikasi Pada Praktek klinis% edisi & . 8a$a%#a : ;. M;l/!$ey- 8/anne = l/%'a M E"lehe$- *2000,- "ursing !lassificatian ("'!)- Se/n - e F/%$- M/!(y.
'utcome
GGGGGGGGG- *200,- "ursing *nter+ention !lassificatian ("*! ,- Se/n - e F/%$- M/!(y. AA- *2009,. "ursing Diagnoses $ Definition and !lassification ,--./,-00. AA In#e%na#'/nal. Ph'lael&h'a. P/##e%- Pa#%''a. 200. Buku Ajar 1undamental Keperawatan : K/n!e&- P%/!e!P%a$#e$- '!' 4. 8a$a%#a : ;. Smel#e% an Ea%e. *2002,# Keperawatan 2edikal Bedah. 8a$a%#a: ; Tam!"%'- A. *2007,. Konsep dan Penatalaksanaan "3eri# 8a$a%#a : ;.
