PRAKTEK KEPERAWA KEPERAWATAN DASAR PROFESI (KDP) LAPORAN PENDAHULUAN ASUHAN KEPERAWATAN PADA PASIEN DENGAN MASALAH PEMENUHAN KEBUTUHAN DASAR OKSIGENASI DI RUANG KENANGA RSUD SLEMAN
Disusun Oleh : SULISTIARNI 3!"#$$
PENDIDIKAN PROFESI NERS ANGKATAN %I SEKOLAH TINGGI ILMU KESEHATAN &ENDERAL A'HMAD ANI OGAKARTA #!"
HALAMAN PENGESAHAN LAPORAN PENDAHULUAN ASUHAN KEPERAWATAN PADA PASIEN DENGAN MASALAH PEMENUHAN KEBUTUHAN DASAR OKSIGENASI DI RUANG KENANGA RSUD SLEMAN
Dish*n +, H-i. /n00l : Oleh
:
Mhsis1
Pe2i2in0 Klini*.'I
Pe2i2in0 A*,e2i*
Sulis/i-ni
'h-is/in D1i Eni45 SST
De6 7ul*-nin Rh,in S6h45 MMR
A. KONSEP KEBUTUHAN DASAR MANUSIA OKSIGENASI 1. Definisi O*si0ensi ,lh +e2enuhn *n *eu/uhn 8*si0en (O9)4
Keu/uhn isi8l80is 8*si0ensi 2e-u+*n *eu/uhn ,s- 2nusi 6n0 ,i0un*n un/u* *eln0sun0n 2e/8lis2e sel /uuh5 un/u* 2e2+e-/hn*n hi,u+n65 ,n un/u* */i;i/s e-0i 8-0n /u sel4 A+il leih ,-i < 2eni/ 8-n0 /i,* 2en,+/*n 8*si0en 2* *n e-*i/ +, *e-us*n 8/* 6n0 /i,* ,+/ ,i+e-i*i ,n isn6 +sien *n 2enin00l4 Keu/uhn 8*si0ensi 2e-u+*n *eu/uhn ,s- 2nusi 6n0 ,i 0un*n un/u* *eln0sun0n 2e/8lis2e sel /uuh 2e2+e-/hn*n hi,u+ ,n */i;i/s e-0i 8-0n /u sel4 Dl2 *e,n is 2nusi 2e2u/uh*n se*i/- 3## == 8*si0en se/i+ h-i (< >2) /u se*i/- #5? == /i+ 2eni/4 Res+i-si e-+e-n ,l2 2e2+e-/h*n *eln0sun0n 2e/8lis2e sel4 Sehin00 ,i +e-lu*n un0si -es+i-si 6n0 ,e*u/4 Res+i-si >u0 e--/i 0un0n */ii/s 2e*nis2e 6n0 e-+e-n ,l2 +-8ses su+li O9 *e selu-uh /uuh ,n +e2un0n 'O9 (hsil +e2*-n sel)4 Te-+i 8*si0en 2e-u+*n slh s/u /e-+i +e-nsn ,l2 2e2+e-/hn*n 8*si0ensi4 Tu>un ,-i /e-+i 8*si0en ,lh un/u* 2e2e-i*n /-ns+8- 8*si0en 6n0 ,e*u/ ,l2 ,-h s2il 2enu-un*n u+6 e-ns ,n 2en0u-n0i s/-ess +, 2i8*-,iu24 O*si0ensi ,lh +-8ses +en2hn 8*si0en O *e ,l2 sis/e2 (*i2i /u isi*)4 O*si0ensi 2e-u+*n 0s /i,* e-1-n ,n /i,* e-u 6n0 sn0/ ,iu/uh*n ,l2 +-8ses 2e/8lis2e sel4 Se0i hsiln65 /e-en/u*lh *-8n ,i8*si,5 ene-0i5 ,n i-4 A*n /e/+i +en2hn 'O 6n0 2eleihi /s n8-2l +, /uuh *n 2e2e-i*n ,2+* 6n0 =u*u+ e-2*n /e-h,+ */ii/s sel4 (Whi/ I@l Mu-*5 ##)4 O*si0en 2e-u+*n *eu/uhn ,s- +lin0 ;i/l ,l2 *ehi,u+n 2nusi5 ,l2 /uuh5 8*si0en e-+e-n +en/in0 ,l2 +-8ses 2e/8lis2 sel /uuh4 Ke*u-n0n 8*si0n is 2en6e*n hl 6n0/ e--/i0i /uu5 slh s/un6 ,lh *e2/in4 K-enn65
e-0i u+6 +e-lu ,il*u*n un/u* 2e>2in +e2enuhn *eu/uhn 8*si0en /e-seu/5 0- /e-+enuhi ,en0n i*4 Dl2 +el*snnn6 +e2enuhn *eu/uhn 8*si0en 2e-u+*n 0-+n +e-1/ /e-sen,i-i5 8leh *-en i/u se/i+ +e-1/ h-us +h2 ,en0n 2nises/si /in0*/ +e2enuhn 8*si0en +, *lien6 se-/ 22+u 2en0/si e-0i 2slh 6n0 /e-*i/ ,en0n +e2enuhn *eu/uhn /e-seu/4 2. Anatomi dan Fisioo!i Sistem Pe"na#asan S/-u*/u- Sis/e2 Pe-nsn 4 Sis/e2 +e-nsn A/s Sis/e2 +e-nsn /s /e-,i-i /s 2ulu/5hi,un05 -in05 ,n l-in04
P, hi,un0 u,-
6n0 2su*
*n 2en0l2i
+en6-in0n5 hu2i,ii*si5 ,n +en0hn0/n4 F-in0 2e-u+*n slu-n 6n0 /e-0i ,u un/u* u,- ,n2*nn4 F-in0 /e-,i-i /s ns8-in0 ,n 8-8-in0 6n0 *6 *n >-in0n li28i, 6n0 e-un0si 2enn0*+ ,n ,n 2en0hn=u-*n *u2n +/h80en 6n0 2su* e-s2 u,-4L-in0 2e-u+*n s/-u*/u- 6n0 2e-u+i /uln0 -1n 6n0 is ,iseu/ >*un4 Selin e-+e-n
se0i
+en0hsil
su-5
l-in0
>u0
e-un0si
2e2+e-/hn*n *e+/enn ,n 2elin,un0i >ln ns 1h ,-i i- ,n 2*nn 6n0 2su*4 4 Sis/e2 +e-nsn B1h Sis/e2 +e-nsn 1h /e-,i-i /s /-*e ,n +-u+-u 6n0 ,ilen0*+i ,en0n -8n*us5 -8n*i8lus5 l;e8lus5 >-in0n *+ile- +-u ,n +leu-4 T-*e 2e-u+*n +i+ 2e2-n 6n0 ,i*8s8n0*n 8leh =in=in *-/il08 6n0 2en0huun0*n l-in0 ,n -8n*us u/2 *nn ,n *i-i4 P-u+-u , ,u uh /ele/* ,i seelh *nn ,n *i-i4 Msin0 2sin0 +-u /e-,i-i /s ee-+ l8us (+-u *nn 3 l8us ,n +-u *i-i l8us) ,n ,i+s8* 8leh s/u -8n*us4 &-in0n>-in0n +-u sen,i-i /e-,i-i /s se-n0*in >ln ns 6n0 e-=n0 =n05 6i/u l;e8ulus5 +e2uluh ,-h +-u5 ,n >-in0n i*/ els/i=4 Pe-2u*n lu- +-u+-u ,il+isi 8leh ,u l+is +elin,un0
6n0 ,iseu/ +leu-4 Pleu- +-ien/l 2e2/si /8-l* ,n +e-2u*n ,i-025 se,n0*n +leu- ;is=e-l 2e2/si +e-2u*n lu- +-u4 Din/- *e,u l+isn /e-seu/ /e-,+/ =i-n +leu- 6n0 e-un0si se0i +elu2s 0un 2en=e0h 0e-*n -i*si sel2 e-ns4 Be-,s-*n /e2+/n6 +-8ses +e-nsn /e-0i 2en>,i ,u 6i/u: !)4 Pe-n+sn e*s/e-nl Pe-n+sn e*s/e-nl (+e-n+sn +ul28ne-) 2en0=u +, *eselu-uhn +-8ses +e-/u*-n O ,n 'O n/- lin0*un0n e*s/e-nl ,n sel /uuh4 Se=- u2u2 +-8ses ini e-ln0sun0 ,l2 /i0 ln0*h5 6*ni : ) Cen/ilsi +ul28ne- S/ e-n+s5 u,- e-0n/in 2su**elu- +-u 2ellui +-8ses ;en/ilsi sehin00 /e->,i +e-/u*-n 0s n/- lin0*un0n e*s/e-nl ,n l;e8lus4 P-8ses ;en/ilsi ini ,i+en0-uhi 8leh ee-+ =/8-5 6i/u >ln n+s 6n0 e-sih5 s6s/e2 s- +us/ ,n s6s/e2 +e-n+sn 6n0 u/uh5 -8n00 /8-*s 6n0 22+u 2en0e2n0 ,n e-*8n/-*si ,en0n i*5 se-/ *82+lins +-u 6n0 ,e*u/4 ) Pe-/u*-n 0s l;e8l- Se/elh 8*si0en 2su*
l;e8l-5
+-8ses
+-8ses
+e-n+sn e-i*u/n6 ,lh ,iusi 8*si0en ,-i l;e8lus *e +e2uluh
,-h
+ul28ne-4 Diusi
,lh
+e-0e-*n
28le*ul ,-i -e e-*8nsen/-si /u e-/e*nn /in00i *e -e e-*8nsen/-si /u e-/e*nn -en,h4 P-8ses ini e-ln0sun0
,i
l;e8lus
,n
2e2-n
*+ile-5
,n
,i+en0-uhi 8leh *e/eln 2e2-n se-/ +e-e,n /e*nn 0s4 =) T-ns+8- 8*si0en ,n *-8n ,i8*si, Th+ *e /i0 +, +-8ses +e-n+sn ,lh /-n+8- 0s 0s +e-n+sn4 P, +-8ses ini5 8*si0en ,in0*u/ ,-i +-u
2enu>u >-in0n ,n *-8n ,i8*si, ,in0*u/ ,-i >-in0n *e2li 2enu>u +-u4 )
Pe-n+sn in/e-nl Pe-n+sn in/e-nl (+e-n+sn >-in0n) 2en0>u +, +-8ses
2e/8lis2e
in/-
sel
6n0
e-ln0sun0
,l2
2i/8*8n,-i5 6n0 2en00un*n 8*si0en ,n 2en0hsil*n 'O sel2 +-8ses +en6e-+n ene-0i 28le*ul nu/-ien4 P, +-8ses ini ,-h 6n0 n6* 2en0n,un0 8*si0en ,i1 *e selu-uh /uuh hin00 2en=+i *+ile- sis/e2i*4 Seln>u/n6 /e->,i +e-/u*-n O ,n 'O n/- *+ile- sis/e2i* ,n sel >-in0n4 Se+e-/i ,i *+ile- +-u5 +e-/u*-n ini >u0 2ellui +-8ses ,iusi +si 2en0i*u/i +enu-unn 0-,ien /e*nn +-sil4 $. Etioo!i F*/8-*/8- 6n0 2en6e*n *lien 2en0l2i 0n00un
8*si0ensi
2enu-u/
NANDA
(#!?)5
6i/u
hi+e-;en/ilsi5
hi+8;en/ilsi5 ,e8-2i/s /uln0 ,n ,in,in0 ,,5 n6e-i5 =e2s5 +enu-unn ene-065.*elelhn5 *e-us*n neu-82us=ul-5 *e-us*n 2us*8l8s*ele/l5 *e-us*n *80ni/i . +e-se+si5 8esi/s5 +8sisi /uuh5 i2/u-i/s neu-8l80is *elelhn 8/8/ +e-nsn ,n ,n6 +e-uhn 2e2-ne *+ile-l;e8li4 %. Fa&to" #"edis#osisi a. F*/8- Fisi8l80i Menu-unn6 *+si/s +en0in0/n O se+e-/i +, ne2i4 • Menu-unn6 *8nsen/-si O 6n0 ,iins+i-si se+e-/i +, • •
8s/-u*si slu-n n+s 0in /s4 Hi+8;8le2i sehin00 /e*nn ,-h 2enu-un 2en0*i/*n
•
/-ns+8-/ O /e-0n00u4 Menin0*/n6 2e/8lis2e se+e-/i ,n6 ine*si5 ,e225 iu
•
h2il5 lu*5 ,n linlin4 K8n,isi 6n0 2e2en0-uhi +e-0e-*n ,in,in0 ,, se+e-/i +, *eh2iln5 8esi/s5 2us*ulus s*ele/8n 6n0 n8-2l5 +en6*i/ *-8ni* se+e-/i TB' +-u4
4 F*/8-Pe-*e2n0n B6i +-e2/u- 6n0 ,ise*n *u-n0n6 +e2en/u*n •
•
su-*/n4 B6i ,n /8,,le- ,n6 -isi*8 ine*si slu-n +e-n+sn *u/4 An* usi se*8lh ,n -e2>5 -isi*8 ine*si slu-n
•
+e-n+sn ,n 2e-8*8*4 De1s 2u, ,n +e-/en0hn : ,ie/ 6n0 /i,* seh/5 *u-n0
•
*/i;i/s5 s/-ess 6n0 2en0*i/*n +en6*i/ >n/un0 ,n •
+-u+-u4 De1s /u : ,n6 +-8ses +enun 6n0 2en0*i/*n *e2un0*inn -/e-i8s*le-8sis5 els/isi/s 2enu-un5 e*s+nsi
+-u 2enu-un4 =4 F*/8- Pe-il*u Nu/-isi : 2isln6 +, 8esi/s 2en0*i/*n +enu-unn • e*s+nsi +-u5 0ii 6n0 u-u* 2en>,i ne2i sehin00 ,6 i*/ 8*si0en e-*u-n05 ,ie/ 6n0 /in00i le2* 2eni2ul*n
•
-/e-i8*le-8sis4 Ee-=ise *n 2enin0*/*n *eu/uhn 8*si0en4 Me-8*8* : ni*8/in 2en6e*n ;s8*8n/-i*si +e2uluh ,-h
•
+e-ie- ,n *8-8ne-4 Sus/nsi use (l=8h8l ,n 8/8/n) : 2en6e*n
•
in/*e •
nu/-isi.Fe
2enu-un
2en0*i/*n
+enu-unn
he280l8in5 l=8h8l5 2en6e*n ,e+-esi +us/ +e-n+sn4 Ke=e2sn : 2en6e*n 2e/8lis2 2enin0*/
,4 F*/8- Lin0*un0n Te2+/ *e-> Suhu lin0*un0n • Ke/in00in /e2+/ ,n +e-2u*n lu/4 • '. Patofisioo!i P-8ses +e-/u*-n 0s ,i+en0-uhi 8leh ;en/ilsi5 ,iusi ,n •
/-s+8-/si4 P-8ses ;en/ilsi (+-8ses +en0hn/-n >u2lh 8*si0en 6n0 2su* ,n *elu- ,-i ,n *e+-u+-u)5 +il +, +-8ses ini /e-,+/ 8s/-u*si 2* 8*si0en /i,* ,+/ /e-slu- ,en0n i* ,n su2/n /e-seu/ *n ,i-es+8n >ln ns se0i en, sin0 6n0
2eni2ul*n +en0elu-n 2u*us4 P-8ses ,iusi (+en6lu-n 8*si0en ,-i
l;e8li
*e>-in0n)
6n0
/e-0n00u
*n
2en6e*n
*e/i,*ee*/in +e-/u*-n 0s4 Selin *e-us*n +, +-8ses ;en/ilsi5 ,iusi5 2* *e-us*n +, /-ns+8-/si se+e-/i +e-uhn ;8lu2e se*un=u+5 afterload 5 preload 5 ,n *8n/-*/ili/s 2i8*-, >u0 ,+/ 2e2+en0-uhi +e-/u*-n 0s (B-unne- Su,,-/h5 ##)4 Fun0si sis/e2 >n/un0 ilh 2en0hn/-*n 8*si0en5 nu/-ien5 ,n su/nsi lin *e >-in0n ,n 2e2un0 +-8,u* sis 2e/8lis2e selul- 2ellui +82+ >n/un05 sis/e2 ;s*ul- si-*ulsi5 ,n in/e0-i/s sis/e2 linn64 N2un un0si /e-seu/ ,+/ /e-0n00u ,ise*n 8leh +en6*i/ ,n *8n,isi 6n0 2e2+en0-uhi i-2 >n/un05 *e*u/n *8n/-*si5 li-n ,-h 2ellui *2-*2- +, >n/un05 li-n ,-h 2i8*-, ,n si-*ulsi +e-ie-4 Is*e2i 2i8*-, /e->,i il su+li ,-h *e 2i8*-, ,-i -/e-i *8-8ne- /i,* =u*u+ ,l2 2e2enuhi *eu/uhn 8*si0en 8-0n4 Selin i/u5 +e-uhn un0si +e-n+sn >u0 2en6e*n *lien 2en0l2i 0n00un 8*si0ensi4 Hi+e-;en/ilsi 2e-u+*n su/u *8n,isi ;en/ilsi 6n0 e-leih5 6n0 ,iu/uh*n un/u* 2en0eli2insi *-8n,i8*si, n8-2l ,i ;en5 6n0 ,i+-8,u*si 2ellui 2e/8lis2e selule-4 Hi+8;en/ilsi /e->,i *e/i* ;en/ilsi l;e8l- /i,* ,e*u/ 2e2enuhi *eu/uhn 8*si0en /uuh /u 2en0eli2insi 'O se=- ,e*u/4 A+il ;en/ilsi l;e8l- 2enu-un5 2* P'O *n 2enin0*/4 Se2en/- hi+8*si ,lh 8*si0ensi >-in0n 6n0 /i,* ,e*u/ +, /in0*/ >-in0n4 (. Manifestasi &inis Su- n+s /i,* n8-2l4 • Pe-uhn >u2lh +e-n+sn4 • B/u* ,ise-/i ,h*4 • Pen00unn 8/8/ /2hn +e-n+sn4 • Dis+ne4 • Penu-unn hlu-n u-in4 • Penu-unn e*s+nsi +-u4 • T*hi+ne • ). Tanda dan !e*aa
A,n6
+enu-unn /e*nn
ins+i-si.
e*s+i-si 2en>,i
/n,
0n00un 8*si0ensi4 Penu-unn ;en/ilsi +e-2eni/5 +en00unn 8/8/ ns /2hn un/u* e-ns5 +e-nsn ns -in0 (ns =u+in0 hi,un0)5 ,is+ne5 8-/8+ne5 +en6i2+n0n ,,5 ns +en,e*5 ns ,en0n 2ulu/5 e*s+i-si 2e2n>n05 +enin0*/n ,i2e/e- n/e-i8- +8s/e-i8-5 -e*uensi ns *u-n05 +enu-unn *+si/s ;i/l 2en>,i /n, ,n 0e>l ,n6 +8l ns 6n0 /i,* ee*/i sehin00 2en>,i 0n00un 8*si0ensi (NANDA5 #!?)4 Bee-+ /n, ,n 0e>l *e-us*n +e-/u*-n 0s 6i/u /*i*-,i5 hi+e-*+ne5 *elelhn5 s82n8len5 i-i/ili/s5 hi+8*si5 *ein0un0n5 sin8sis5 1-n *uli/ n8-2l (+u=/5 *ehi/2hi/2n)5 hi+8*se2i5 hi+e-*-i5 s*i/ *e+l *e/i* n0un5 n8-2l -e*uensi5 i-2 ,n *e,l2n ns4 B. PENGKA+IAN F8*us Pen0*>in a. Ri16/ Ke+e-1/n 1, Mslh *e+e-1/n 6n0 +e-nh ,il2i Pe-nh 2en0l2i +e-uhn +8l +e-n+sn4 Pe-nh 2en0l2i /u* ,en0n s+u/u24 Pe-nh 2en0l2i n6e-i ,,4 A*/i;i/s + s> 6n0 2en6e*n /e->,in6 0e>l0e>l ,i /s4 2, Ri16/ +en6*i/ +e-n+sn A+*h se-in0 2en0l2i ISPA5 le-0i5 /u*5 s25 TB'5 ,n linlin B0i2n -e*uensi se/i+ *e>,in $, Ri16/ *-,i8;s*ule- Pe-nh 2en0l2i +en6*i/ >n/un0 (00l >n/un05 00l ;en/-i*el *nn5,ll) /u +e-e,-n ,-h4 %, G6 hi,u+ Me-8*8* 5 *elu-0 +e-8*8*5 lin0*un0n *e-> ,en0n +e-8*8*4 -. Pe2e-i*sn Fisi* !4 M/ *8n>un0/i; +u=/ (*-en ne2i) *8n>un0/i; sin8sis (*-en hi+8*se2i)
*8n>un0/i; /e-,+/ +e/he=hi (*-en e28li le2* /u en,8*-,i/is) 2. Kuli/ Sin8sis +e-ie- (;s8*8n/-i*si ,n 2enu-unn6 li-n ,-h
$.
%.
'. (. ).
+e-ie-) Penu-unn /u-08- (,ehi,-si) E,e24 E,e2 +e-i8-i/l4 &-i ,n *u*u Sin8sis4 'luin0 in0e-4 Mulu/ ,n ii- Me2-ne 2u*8s sin8sis Be-n+s ,en0n 2en0e-u/*n 2ulu/4 Hi,un0 Pe-n+sn ,en0n =u+in0 hi,un04 Cen lehe- A,n6 ,is/ensi . en,un0n4 D, Re/-*si 8/8/ Bn/u +e-n+sn (*-en +enin0*/n */i;i/s +e-n+sn5 ,is+ne5 8s/-u*si >ln +e-n+sn)4 Pe-0e-*n /i,* si2e/-is n/- ,, *i-i ,n ,, *nn4 T=/il -e2i/us5 /h-ills (0e/-n +, ,, *-en u,-.su- 2ele1/i slu-n.-8n00 +e-n+sn) Su- n+s n8-2l (;esi*ule-5 -8n=h8;esi*ule-5 -8n=hil) Su- n+s /i,* n8-2l (=-e*le-l-.-les5 -8n*hi5 1heein05
-i=/i8n -u.+leu-l -i=/i8n) Bun6i +e-*usi (-es8nn5 hi+e-es8nn5 ,ullness) . P8l +e-n+sn Pe-n+sn n8-2l(eu+ne) Pe-n+sn =e+/ (/=6+ne) Pe-n+sn l2/ (-,6+ne) /. Pe2e-i*sn +enun>n0 EKG E=h8=-,i80-+h6 K/e/e-issi >n/un0 An0i80-i 0. DIAGNOSIS Di0n8s 6n0 2un0*in 2un=ul +, *lien ,en0n 0n00un 8*si0ensi ,lh:
4 4 =4 ,4
Ke/i,*ee*/in e-sihn >ln ns Gn00un +e-/u*-n 0s Ke/i,*ee*/in +8l ns N6e-i e-huun0n ,en0n is*e2i >-in0n se*un,e- /e-h,+
su2/n -/e-i4 e4 Resi*8 +enu-unn =u-h >n/un0 e-huun0n ,en0n +e-uhn =/8-*/8- lis/-i*5 +enu-unn *-*/e-is/i* 2i8*-,4 4 Gn00un +e-usi >-in0n e-huun0n ,en0n 5 is*e2i*5 *e-us*n 8/8/ >n/un05 +en6e2+i/n . +en6u2/n +e2uluh ,-h -/e-i *8-8n-i4 04 Ke-us*n +e-/u*-n 0s e-huun0n ,en0n 0n00un li-n ,-h *e l;e8li /u *e00ln u/2 +-u5 +e-uhn 2e2-n l;e8l- *+ile- (/ele*/sis 5 *8l+s >ln ns. l;e8l- e,e2 +-u.eusi5 se*-esi e-leihn . +e-,-hn */i )4 h4 In/8le-nsi */ii/s e-huun0n ,en0n *e/i,*sei2n0n n/- su+li 8*si0en 2i8=-, ,n *eu/uhn5 ,n6 is*e2i*. ne*-8/i* >-in0n 2i8=-, ,i/n,i ,en0n 0n00un -e*uensi >n/un05 /e*nn ,-h ,l2 */ii/s5 /e->,in6 ,is-i/2i5 *ele2hn u2u24 D. REN0ANA INTERENSI N O D % !
TU&UAN NO'
Se/elh ,il*u*n /in,*n *e+e-1/n sel2 < >2 ,ih-+*n e-sihn >ln n+s ee*/i sesui ,en0n *-i/e-i: !4 Me2ili*i RR ,l2 /s n8-2l 4 Me2ili*i i-2 +e-nsn 6n0 n8-2l 34 M2+u 2en0elu-*n s+u/u2 ,-i >ln ns <4 Bes ,-i su- ns /2hn
INTERCENSI NI'
!4
Ten/u*n *eu/uhn suction 8-l ,n /u /-*hel 4 Aus*ul/si su- ns sesu,h ,n seelu2 2el*u*n su=/i8n 34 In8-2si*n *e+, *lien ,n *elu-0 /en/n0 su=/i8n <4 M8ni/8- s//us 8*si0en +sien (/in0*/ SO ,n S;O) ,n s//us he28,in2i* (/in0*/ MAP [mean arterial pressure] ,n i-2 >n/un0) se0e- seelu25 sel2 ,n se/elh su=/i8n ?4 Pe-h/i*n /i+e ,n >u2lh se*-esi 6n0 ,i*u2+ul*n
Se/elh ,il*u*n /in,*n *e+e-1/n sel24%< >2 ,ih-+*n +8l n+s ee*/i ,en0n *-i/e-i : !4 Me2ili*i RR ,l2 /s n8-2l 4 M2+u ins+i-si ,l2 34 Me2ili*i ,, 6n0 2en0e2n0 se=- si2e/-is <4 D+/ e-ns ,en0n 2u,h ?4 Ti,* 2en00un*n 8/8/8/8/ /2hn ,l2 e-ns "4 Ti,* 2en0l2i ,is+ne
!4 M8ni/8- -/-/5 i-25 *e,l2n ,n ush -es+i-si 4 Pe-h/i*n +e-0e-*n ,,5 2/i *ese2e/-isn5 +en00unn 8/88/8/ *ses8-is5 ,n -e/-*si 8/8/ su+-*l;i*ule- ,n in/e-*8s/l 34 M8ni/8- -es+i-si 6n0 e-un6i5 se+e-/i 2en,en0*u- <4 M8ni/8- +8l +e-nsn: -,i+neu5 /*i+neu5 hi+e-;en/ilsi5 -es+i-si Kussmaul 5 -es+i-si CheyneStokes5 ,n +neus/i* Bi8/ ,n +8l /i= ?4 Pe-h/i*n l8*si /-*e "4 M8ni/8- +enin0*/n *e/i,*22+un is/i-h/5 *e=e2sn5 ,n hus u,-5 +e-h/i*n +e-uhn +, SO5 S;O5 'O *hi-/i,l5 ,n nili 0s ,-h -/e-i (AGD)5 ,en0n /e+/
3
Se/elh ,il*u*n /in,*n *e+e-1/n sel2 4% < >2 ,ih-+*n +e-/u*-n 0s i* ,en0n *-i/e-i : !4 D+/ e-ns ,en0n 2u,h 4 Ti,* 2en0l2i ,is+ne 34 Ti,* 2en0l2i sin8sis <4 Ti,* 2en0l2i s82n8len ?4 Me2ili*i +e-usi ;en/ilsi 6n0 sei2n0
!4 P8sisi*n *lien un/u* 2e2*si2l*n +8/ensi ;en/ilsin64 4 I,en/ii*si *eu/uhn *lien *n inse-si >ln ns i* */ul 2u+un +8/ensil4 34 L*u*n /e-+i isi* ,, <4 Aus*ul/si su- ns5 /n,i -e +enu-unn /u hiln0n6 ;en/ilsi ,n ,n6 un6i /2hn ?4 M8ni/8- s//us +e-nsn ,n 8*si0ensi5 sesui *eu/uhn
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Se/elh ,il*u*n Ene"! Mana!ement /in,*n *e+e-1/n !4 K>i +e-sn ;e-l /en/n0 sel2 < >2 *e=u*u+n ene-06 ,ih-+*n /i,* /e->,i 4 K>i +en6e *elelhn
in/8le-nsi */i;i/s sesui *-i/e-i: A/ti3it Toe"an/e !4 F-e*uensi >n/un0 ,l2 -en/n0 n8-2l s/ 2e-es+8n */i;i/s 4 F-e*uensi n+s ,l2 -en/n0 n8-2l s/ 2e-es+8n */i;i/s
se+e-/i n6e-i5 +en08/n5 ,ll 34 M8ni/8in/*e nu/-isi se=- ,e*u/ se0i su2e- ene-06 <4 M8ni/8- l+8-n +8l /i,u- +sien se-/ l2n6 /i,u- e-+ >2 ?4 B/si s/i2ulsi lin0*un0n se+e-/i =h6 ,n *eisin0n un/u* -el*ssi "4 An>u-*n e,-es/ /u /si *e0i/n se+e-/i 2enin0*/*n 1*/u +e-i8,e /i,u- . is/i-h/ 4 A>-*n +, +sien /u *elu-0 /n, /n, *elelhn ,n n>u-*n 2en0u-n0i */i;i/s4
DAFTAR PUSTAKA
T-18/8 W-/8nh4 (#!#)4 Kebutuhan Dasar Manusia Dan Proses Keperawatan. E,isi <4 Sle2 Me,i* : &*-/ B-unne- Su,,-/h4 (##)4 Ke+e-1/n Me,i*l Be,h4 EG'4 &*-/ Mu-*5 Whi/ I@l 'h6ni5 Nu-ul4 ##4 Kebutuhan Dasar 4 &*-/ : EG' Nn, In/e-n/i8nl (#!?)4 Dianosis Keperawatan! definisi " Klasifikasi4 #!?#!4 Pene-i/ u*u *e,8*/e-n EG' : &*-/ #ursin $n%ention Classifications &#$C'5 E,i/i8n ?5 Uni/e, S//es O A2e-i=: M8s6 Else;ei- A=,2i= P-ess5 ##<4 Ms5 M8-he,5 &h8ns8n ,n S1ns8n4 #ursin (ut Comes &#(C'5 Uni/e, S//es O A2e-i=: M8s6 Else;ei- A=,2i= P-ess5 ##<4
