SISTEM INTEGUMEN “LAPORAN “ LAPORAN PENDAHULUAN PENDAHULUA N ASUHAN KEPERAWA KEPERAWATAN DAN HEALTH EDUCATION PRURITUS”
Oleh : KELOMPOK SGD 3
NI PUTU INTAN INTAN PARAMA PARAMA ASTI
1302105007
KADEK LISA DWI BUDAYANI
1302105009
NI PUTU SRI ANGGRENI
1302105021
LUH ANGGARIASIH
1302105023
NI MADE DITA DITA ANDAY ANDAYANI
1302105027
NI LUH DIAH PRADNYA PRADNYA KERTHIARI KERTHIARI
130210503
PUTU MAYA PRIHATNAWATI
13021050!0
HERDI SAHIRLAN
13021050!3
IDA AYU MADE SINTA DEWI
1302105053
NI LUH TRISNAW TRISNAWATI
1302105079
PROGRAM STUDI ILMU KEPERAWATAN "AKULTAS KEDOKTERAN UNI#ERSITAS UDAYANA 2015
A. DEFINI DEFINISI SI 1$ P%&%'(&) P%&%'(&) *+,(,l- .e%&/,, .e%&/,, e(',,. e(',,.,, ,, &(,., ),./,' ('+,( ('+,( %'+, ,(,& 4e%,(
/,, 'l,.,)' &l'( *L6+ B8 1992$ P%&%'(&) P%&%'(&) *+,(,l+,(,l*+,(,l+,(,l- .e%&/,, .e%&/,, ),l,h ),(& ,%' )e&.l,h el&h, el&h, ,+ /,l'+ /,l'+ )e%'+ '&./,' /,, +,++&, e%.,(6l6+' ,+ .e'.4&l, +,++&, %,), ,., , /e%&4,h, '(e+%'(,) &l'( ', /,)'e .e%e)/6, e+, +,%&, *B%&e% , S&,%(h 20023$ P%&%'(& P%&%'(&)) ,,l,h ,,l,h +e,l, +e,l, ,%' ,%' 4e%4,+ 4e%4,+,' ,' /e, /e,'( '( &l'( &l'( 4,' 4,' le)' /%'.e% /%'.e% .,&/& .,&/& le)' )e&e% .e)'/& ,, /%&%'(&) ,+ '('.4&l, ,'4,( ,(6% )')(e.' 6le)' &l'($ &l'($ P%&%'(&) ,+ (', ')e%(,' el,', &l'( ')e4&( ')e4&( pruritus esensial * pruritus pruritus sine materimateri- *D&,, A$ 2007;,' /%&%'(&) *+,(,l- .e%&/,, ),l,h ),(& ,%' )e&.l,h el&h, ,+ /,l'+ )e%'+ '&./,' /,, +,++&, e%.,(6l6+' e+, )e),)' (', .ee,+, ' &l'( ,+ .e'.4&l, .e'.4&l, e'+', e'+', &(& .e++,%&$ .e++,%&$ P%&%'(&) P%&%'(&) ,+ he4,( .ee4,4, .ee4,4, /,)'e .e++,%& &l'( le4'h ,l,. , l,., )eh'++, ,,+ &l'( 4'), ),./,' 4e%,%,h ,%e, )e),)' e%' '(6le%,)' le4'h 4,' ,%'/,, %,), +,(,l$ P%&%'(&) ,+ (', ')e%(,' el,', &l'( ')e4&( )e4,+,' pruritus )e4,+,' pruritus esensial (pruritus sine materi). B. KLASIF KLASIFIKA IKASI SI Be%,),%, e'), /%&%'(&) '4,+' .e,': 1$ P%&%'(&) P%&%'(&) P%'.e% ,,l,h /%&%'(&) /%&%'(&) (,/, ,,, ,,, /e,'( /e,'( e%.,(6l6+' e%.,(6l6+' ,(,& ,l,( ,l,.
, , ,/, ,/,(( 4e%)' 4e%)', ,(( l6, l6,l' l'),( ),(,, ,(,& ,(,& +ee +ee%,l %,l') '),(, ,(, 4'), 4'), 4e%) 4e%)', ',(( /)' /)'6+ 6+e e' ' ,+ ,+ ')e4,4, 6leh 6./ee /)'6+e' ,+ .e.4e%', )('.&l,)' /,, itch centre$ centre$ 2$ P%&%'(&) P%&%'(&) Se&e% Se&e% ,,l,h /%&%'(&) /%&%'(&) ,+ ('.4&l )e4,+,' ,'4,( /e,'( /e,'( )')(e.' /,, /%&%'(&) )')(e.' (6)'(6)' .e(,46l' .&+' (e%('.4& ' <,'%, '(e%)(')'&. '4,=,h &l'($ *D&,, A$ 2007Kl,)'',)' /%&%'(&) 4e%,),%, /,(6')'6l6+', '4,+' .e,' ! ,(e+6%' ,'(&: 1$ G,(,l G,(,l /%&%'(6 /%&%'(6)e/ )e/(' (' ,,l,h +,(,l ,+ 4e%,),l 4e%,),l ,%' ,%' &l'( &l'( , (e%,' (e%,' ,'4,( ,'4,( ,,, ,,, /%&%'(6+e )e/e%(' &l'( ,+ e%'+ (e%,' 'l,.,)' )e%(, (e%,' e%&),, &l'($ 2$ G,(, G,(,ll e&% e&%6/ 6/,( ,(' ' ,,l ,,l,h ,h +,(,l +,(,l ,+ ,+ (e%, (e%,' ' ,'4 ,'4,( ,( (e% (e%,/ ,/,( ,( le)' le)' ' ,%,) ,%,) ,e%e ,e%e /e+h,(,%, './&l) )e/e%(' e&%,l+', , +,++&, )e%e4%6>,)&le%$ )e%e4%6>,)&le%$ 3$ G,(,l e&%6+e' e&%6+e' ,,l,h ,,l,h +,(,l ,+ 4e%,),l ,%' /&),( /&),( *)e(%,l- (,/, (,/, ')e%(,' e,,, /,(6l6+')$ 86(6h, ,,l,h )&.4,(, ,(&+ e./e& ,+ ,, .e'+,(, ,,% )e,=, 6/'6' ,+ ,, .e.'<& ('.4&l, /%&%'(&)$
!$ G,(,l /)'6+e' ,,l,h +,(,l ,+ ,+ '(,) /)'6l6+') , e4',),, 4e%&l,+$ M'),l, e(,&(, (e%h,,/ /,%,)'( */,%,)'(664',- ,/,( .ee4,4, )e),)' +,(,l$ *T=<%6)) *T=<%6)) R e( ,l 2003C. ETIOLO ETIOLOGI GI P%&%'(&) ,/,( ')e4,4, 6leh ,(6% e)6+e ,(,& e6+e$ 1$ E)6+e E)6+e .'),l, .'),l, e%.,('(') e%.,('(') 6(, '%'(, */,,', */,,', l6+,. l6+,. 4e, ,)'+- e%.,('(') e%.,('(')
6(, 6(, ,lle%+ ,lle%+e e *.,, *.,,, , ,%e( ,%e( /e=,+ /e=,+' ' /e%h', /e%h',), ), 4,l)e. 4,l)e. ),4& ),4& .,'.,'- %,+),+, 6leh e(6/,%,)'( *)e%,++, (&+,& ),4'e) /e'&l&) l,%>, .'+%,),(,& ,(6% l'+&+, ,+ .e.4&,( &l'( le.4,4 ,(,& e%'+$ 2$ E6 E6+e +e .'),l .'),l ,, %e, %e,)' )' 64,( 64,( ,(,& ,(,& /e /e,' ,'(( )')(e )')(e.' .' )e/e%( )e/e%('' +,+ +,++& +&, , +' +',l ,l +,++&, .e(,46l' *DM h'/e%('%6'').e , h'/6('%6'').e- , )(%e)) /)'6l6+') ,+ .ee4,4, .e'+,(, )e)'('>'(,) %e)/6 '.&$ Se%'+,l' ,&), )e<,%, l'') 4el&. 'e(,h&'$ *M6)
K&l'( e/,l, P&++&+ Le+,
: Se46%%h6e'< e%.,('(') &(& %,.4&( : N6(,l+', /,%,e)(he('<, : B%,
d.
T,+,
: De%.,('(') (,+, ll$
b.
2$ G,++& G,++&, , )')(e.' )')(e.' Be4e%,/, G,++&, S')(e.' Pee4,4 P%&%'(&) a. b. c.
G,++&, +',l )e/e%(' +,+,l +',l %6'$ G,++&, h,(' )e/e%(' 64)(%&)' 4'l',%') '(%,he/,(', ,(,& e)(%,he/,(',$ E6 E6% %' ' ,(,& ,(,& .e(, .e(,46 46l' l' )e/e )e/e%( %('' ',4 ',4e( e(e) e) .ell .ell'( '(&) &) h'/e h'/e%( %('% '%6' 6'' '). ).e e h'/6/,%,('%6'').e , .@6ee.,$
d.
G,++&, G,++&, /,, ,%,h )e/e%(' e')'e)' )e+ *,e.',- *,e.',- /6l<(h,e. /6l<(h,e.', ', le&'.', le&'.', l'.,(' , H6+') ')e,)e$
3$ G,++& G,++&, , /,, /,, &l' &l'((
Pee4,4 /%&%'(&) ,+ 4e%,),l ,%' +,++&, &l'( ),+,( 4e%,+,.$ Be4e%,/, ',(,%,, ,'(& e%.,('(') 6(, '%'(, , ,le%+' &l'( e%'+ /%&%'+6 6&l,%') &%(',%', /)6%',)') e%.,('(') ,(6/'< 6l'&l'(') &(& )<,4'e) .'l',%', , sunburn$ !$ P,,, (e%h,,/ ,<(6% (e%(e(& P,,, &l'( (e%h,,/ 4e4e%,/, ,<(6% 4,' 4e%,),l ,%' l&,% .,&/& ,l,. ,/,( .ee4,4, /%&%'(&)$ ",(6% ,+ '.,)& ,,l,h ,lle%+e ,(,& 4e(& '%'(, l,', &%(',%', ')',l ,=&,+e'< /%&%'(&) )e%,++, , 64,(64,(, (e%(e(& *(6/'<,l .,&/& )')(e.' <6(6h: 6/'6' ,)/'%'-$ 5$ H6%.6,l D&, /e%)e ,%' =,'(, h,.'l .ee%'(, /%&%'(&) (,/, ,,, +,++&, e%.,(6l6+'<$ P%&%'(&) +%,>',%&. ''&)' 6leh e)(%6+e , (e%,,+ (e%,/,( h&4&+, e+, 6le)(,)')$ P%&%'(&) (e%&(,., (e%,' /,, (%'.e)(e% e('+, eh,.'l, '.&l,' /,, ,46.e ,(,& 4,, e.&', .e,' +ee%,l'),(,$ A, ,l,, /%&%'(&) ')e%(,' e+, ,6%e)' ,&)e, , .&(,h$ P%&%'(&) ,, .e+h'l,+ )e(el,h /ee%'(, .el,h'%,$ I(e%&) 6le)(,)') ('.4&l )e(el,h /ee%'(, .e+,l,.' /%&%'(&) 2! .'++&$ I(e%&) , /%&%'(&) ')e4,4, 6leh ,%e, (e%,/,( +,%,. e./e& ' ,l,. &l'($ Sel,' '(& /%&%'(&) &+, .e,' +e,l, &.&. (e%,' .e6/,&)e$ Se(',, 50C 6%,+ 4e%&.&% 70 (,h& ,(,& le4'h .e+,l,.' /%&%'(&)$ Kel,', &l'( ,+ .ee4,4, /%&%'(&) )e/e%(' )<,4'e) /e./h'+6' 6&l,%') ,(,& e<e., +%,e %e,h /e%l& '/e%('.4,+, )el,' +,++&, )')(e.' )e/e%(' 6le)(,)') ,(,&/& +,+,l +',l$ P,, )e4,+', 4e),% ,)&) /%&%'(&) )/6(, /ee4,4 /%&%'(&) /,, l,)', ,,l,h ee%'+, &l'( ,'4,( /e&,, &l'($ P%&%'(&) /,, l,)', 4e%e)/6 4,' (e%h,,/ /e+64,(, e.6ll'e($ *D&,, 2007D. EPIDEMIOLOGI P%&%'(&) .e+e,' 20C 6%,+ e=,), ' A.e%', Se%',( e+, )e'(,% !050C '
,),%' 6leh /e,'( /ee%(, )'(e.' : 1$ Re,l /%&%'(&) .e+e,' )e'(,% 0C /,)'e 8R" ,+ .e,/,( HD$ P,)'e ,+ (', .e,/,( HD /%e>,l,)', )e'(,% 30C$ 2$ P,)'e 6le)(,)') e+, )'%6)') 4'l'e% /%'.e% 0C .e+,l,.' /%&%'(&)$ 3$ P,)'e /6l')'(e.', >e%, !?70C .e+,l,.' /%&%'(&) ,&,+e'$ !$ H'/e%('%6'').e .ee4,4, /%'%'(&) )e'(,% !11C &.&., /,, /,)'e ,+ (', .e,/,( (e%,/'F/e,+,, ,e&,($ Se,+, /%e>,le)' /%&%'(&) &(& h'/6('%6'').e , DM (', 'e(,h&' e+, /,)(' ,%e, le4'h ,%,+ (e%,'$
5$ P%e>,le)' /%&%'(&) ,+ 4e%h&4&+, e+, e+,,), ),+,( )e''( )e'(,% 1 ?C$ D'6.',)' 6leh H6+' l'.6., )e'(,% 35C ,%' &.l,h e)el&%&h, , 10C 6leh 6h6+' l./h6., *NHL-$ E. MANIFESTASI KLINIS Me&%&( B%&e% , S&,%(h *2000- .,'e)(,)' l'') /%&%'(&) ,,l,h 1$ G,%&, )e%'+ le4'h he4,( /,, .,l,. h,%'
P%&%'(&) )e<,%, h,) ,, .ee4,4, /,)'e .e+,%& ,+ 4',),, 'l,&, )e.,' '(e)' /,, .,l,. h,%'$ P%&%'(&) (', )e%'+ 'l,/6%, /,, ),,( (e%,+, ,%e, /e%h,(', /,)'e (e%,l'h /,, ,('>'(,) )eh,%'h,%'$ P,, .,l,. h,%' '.,, h,lh,l ,+ 4'), .e+,l'h, /e%h,(', h,,l,h )e''( e,,, /%&%'(&) ,+ %'+, )e,l'/& (', .&,h ',4,',$ 2$ E)6%',)' e.e%,h, ,%e, /e66l, /,, &l'(
P,, +,%&, ,&( ,/,( .e'.4&l, &%(',%', )e,+, /,, +,%&, %6' ,/,( .e'.4&l, /e%,%,h, &(, , l'e'',)' *h,)'l ,%' ,('>'(,) .e++,%& ,+ 'l,&, )e<,%, (e%&) .ee%&) e+, /l, ,+ .ee4,l-$ A/,4'l, +,%&, 'l,&, e+, .e++&,, && ,/,( .ee4,4, e)6%',)' l'e,% /,, &l'( , l,)e%,)' /,, &&, )e'%'$ 3$ R,), +,(,l ,+ he4,( ,/,( .ee4,4, e(',.,./&, /,, ''>'& , .e+,++& /e,./'l, /,)'e$ D,l,. 4e4e%,/, ,)&) +,(,l ,+ (e%,' 4',),, ')e%(,' e+, e%' , )e),)' (e%4,,%$
F. PATOFISIOLOGI
P%&%'(&) ,/,( ')e4,4, 6leh ,(6% e)6+e ,(,& e6+e$ ",(6% e)6+e .'),l, e%.,('(') 6(, '%'(, */,,', l6+,. 4e, ,)'+- e%.,('(') 6(, ,lle%+e *.,,, ,%e( /e=,+' /e%h',), 4,l)e. ),4& .,'- %,+),+, 6leh e(6/,%,)'( *)e%,++, (&+,& ),4'e) /e'&l&) l,%>, .'+%,)- ,(,& ,(6% l'+&+, ,+ .e.4&,( &l'( le.4,4 ,(,& e%'+$ ",(6% e6+e .'),l, %e,)' 64,( ,(,& /e,'( )')(e.' )e/e%(' +,++&, +',l +,++&, .e(,46l' *DM h'/e%('%6'').e , h'/6('%6'').e- , )(%e)) /)'6l6+') ,+ .ee4,4, .e'+,(, )e)'('>'(,) %e)/6 '.&$ Se%'+,l' ,&), )e<,%, l'') 4el&. 'e(,h&' *M6)
)e4,+,'
,+e
/%&%'(6+e'$
G,++&,
.e(,46l').
)e/e%('
DM
h'/e%('%6'').e , h'/6('%6'').e &+, .e%&/,, /ee4,4 ('.4&l, /%&%'(&) )el,' '(& /ee4,4 l,', )e/e%(' /e,'( he/,% ,, .ee4,4, 6le)(,)') *)&.4,(, ,(&+ e./e&- ,+ ,/,( .e'+,(, )'(e)') )e,=, 6/'6'$ ",(6% l,' )e/e%(' )(%e)) ,+ &+, 4e%/e+,%&h (e%h,,/ ('.4&l, /%&%'(&) ,%e, )(%e)) .e'+,(, )e)'('>'(,) %e)/6 '.& h,l '' .e+,'4,(, )')(e. '.& .ele/,), .e',(6% 'l,.,)' )e<,%, 4e%le4'h, , .ee4,4, )&4)(,)' P .e)e)'('),)' 6)')e/(6% )e<,%, '.',='$ P%6)e) '.&6l6+' )e4,+,' ),l,h ),(& ,(6% e6+e l,', ')e4,4, ,%e, (e%/,/,% 4,h, ,lle%+e */e=,+' /e+,=e( /e%h',), /e=,%, %,.4&( 4,l),. ,%e(- ,, .e+,'4,(, %e,)' '.&6l6+' *,lle%+e (e%',( e+, /%6(e' .e.4e(& ,('+e le+,/ ,('+e '(,+,/ , '/%6)e) 6leh .,%6,+ , )el l,+e%h,) ,('+e ,+ (el,h '/%6)e) '/%e)e(,)', 6leh )el T )el T 4e%'e%e)',)' , 4e%/l6%'e%,)' .e.4e(& )el T ee(6% ,+ (e%)e)'('),)' )e<,%, )/e)'' , )el
.e.6%' (e%)e4,% e )el&%&h (&4&h .ee4,4, e,,, )e)'('>'(,) ,+ ),., ' )el&%&h &l'( (&4&h , ,/,4'l, (e%/,/,% 4,h, ,lle%+e e.4,l' .,, ,, .e)('.&l,)' &&+ ),%, 4e4,) ' e,( &<('6 e%.6e/'e%.') e.&', .e%,+),+ e/'e%.') , /e%<,4,+, )e%,4&( ),%, ('/e 8 (, (e%.'el',)'$ Sel,&(, 6%(e) )e%e4%' .e./e%)e/)', )('.&l&) +,(,l .el,l&' ,%,) ,)ee ,+ .e.'<& ('.4&l, /%&%'(&) , ,,, )<%,(
,+ .e'.4&l, +,++&, %,), ,., , /e%&4,h,
'(e+%'(,) &l'( ', /,)'e .e%e)/6, e+, +,%&,$ Re)e/(6% %,), +,(,l (', 4e%.'el' .e./&,' &&+ ),%, .'%'/ )',( */e'<',(e- ,+ h,, '(e.&, ,l,. &'( .e.4%,e .&6), , 6%e, *She% 1992 ,l,. B%&e%S&,%( 2002-$ G,%&, .ee4,4, (e%,', 'l,.,)' )el , /ele/,), h')(,.'e 6leh &&+ ),%, ,+ .e./e%4e%,(
/%&%'(&) ,+ )el,&(, .e+h,)'l, %,), +,(,l ,
.e++,%&$ Me)'/& /%&%'(&) 4',),, ')e4,4, 6leh /e,'( &l'( ,+ /%'.e% e+, (e%,', %&,. ,(,& le)' )e4,+,' ,'4,(, ,.& e,,, '' 4'), ('.4&l (,/, .,'e)(,)' &l'( ,/,/&$ Ke,,, '' ')e4&( )e4,+,' e)e)',l ,+ &.&., .e.'l'' ,='(, ,+ '(,) h'&/ )eh,%'h,%' ,+ 6%.,l$ P%&%'(&) &+, ,/,( .ee4,4, (e%,', e%&),, '(e+%'(,) &l'( ,'4,( e%&),, &l'( *e%6)' e)e%',)'- ,+ '/'<& 6leh %,+),+, ,%' ),%, .6(6%'$
Faktor Eksog!
Faktor E!"og!
P%6)e) '.&6l6+' K&l'( e%'+
P,,, (e%h,,/ ,(6% (e%(e(& *,( '.', , %,+),+, ')' , .e,'- .'),l, l6+,.
Ke%&),, &l'( 6leh /%&%'(6+e
Te%/,/,% 4,h, ,lle%+e */e=,+' /e+,=e( /e%h',), /e=,%, %,.4&( 4,l),. ,%e(*Re,)' '.&6l6+'- : ,lle%+e (e%',( e+, /%6(e' .e.4e(& ,('+e le+,/
Pe,'( )')(e.'
Pe,'( he/,%
Mee4,4, 6le)(,)') *)&.4,(, ,(6+ e./e&-
A('+e '(,+,/ , '/%6)e) 6leh .,%6,+ , )el L,+e%h,) A('+e ,+ (el,h '/%6)e) '/%e)e(,)e, 6leh )el T
Me'+,(, )'(e)') )e,=, 6/'6'
Sel T 4e%'e%e)',)' , 4e%/l6%'e%,)' .e.4e(& )el T ee(6% ,+ (e%)e)'('),)' )e<,%, )/e)'' , )el .e.6%'
Te%)e4,% e )'%&l,)' )el&%&h (&4&h
Mee4,4, e,,, )e)'('>'(,) ,+ ),., ' )el&%&h (&4&h
A
Te%/,/,% 4,h, ,lle%+e e.4,l' */e=,+' /e+,=e( /e%h',), /e=,%, %,.4&( 4,l),. ,%e(-
B
C
G,++&, .e(,46l').e G,++&, +',l : 8KD D',4e(e) .el'(&)
Pe'+,(, &%e&. )e%&.
A46%.,l'(,) .e(,46l'< ')&+)' 6(66.' ,h'%6)') e&%6/,(' ',4e('
H'/e%('%6'').e
Pe&%&, ,.4,+ 4,(,) +,(,l
Be%6(%'4&)' )e4,+,' ,+e /%&%'(6+e'
D
H'/6('%6'').e
e%6)')
S(%e))
H6%.6,l
Me'+,(, )e)'('>'(,) %e)/6 '.&
I&)' h6%.6e e)(%6+e /,, (%'.e)(e% e3 /,, eh,.'l,
S)(e. '.& .ele/,), .e',(6% 'l,.,)' )e<,%, 4e%le4'h,
Te%,/,( h&4&+, e+, 6le)(,)')
S&4)(,)' P .e)e)'('),)' 6)')e/(6% )e<,%, '.',=' *El>', PA 20110
Te%,/,( +,%,. e./e& ' ,l,. &l'(
Me'+,(, )'(e)') )e,=, 6/'6'
E
B
A
C
D
E
S('.&l,)' &&+ ),%, 4e4,) ' e,( &<('6 e%.6e/'e%.,l
Me%,+),+ e/'e%.') , /e%<,4,+, )e%,4&( ),%, ('/e 8 (, (e%.'el',)'
R,), +,(,l (e%&) .ee%&)
T', ,/,( ',4,',
Ga!gg&a! Rasa N)a*a!
K6%(e) )e%e4%' .e./e%)e/)', )('.&l&) +,(,l *.el,l&' ,%,) ,)ee-
PRURITUS
S<%,(
G,%&,
Il,.,)' )el , /ele/,), h')(,.'e 6leh &&+ ),%,
Il,.,)' 4e%l,+)&+ l,.,
Me'.4&l, %&,. , le)' Ga!gg&a! C$tra T&'&% Kr&saka! I!tgr$tas K&($t
Pele/,), .e',(6% '.', *4%,''' )e%6(6' h')(,.'e .e%,+),+ %e)e/(6% e%'-
N)r$ Ak&t
G. PEMERIKSAAN PENUN+ANG
Pe.e%'),, /e&,+ '4&(&h, &(& .e+e(,h&' /ee4,4 /%&%'(&) =,l,&/& /e.e%'),, l'') &+, 4'), .e,,' ,,, el,', )')(e.' (e%(e(&$ Pe.e%'),, ,+ 4'), 'l,&, &(& .e',+6)') e.&+', /%&%'(&) ,%e, /e,'( /ee%(, )')(e.' ,(,%, l,' : N6$ ;e') Pe.e%'),, 1
H'(&+
,%,h
le+,/ *8B8-
Te.&,
H<( 5C Pe'+,(,
M8# 9? l RB8 6%.,l ,(,&
Pee%(,
;e') P%&%'(&)
S')(e.' P6l')'(e.',
P%&%'(&)
#e%,
He.,(6l6+')
Ae.',
J2? e')'e)' 4e)'
&(,F..3 H4 .e&%&
J10+%Fl Pe&%&, M8#
M8H
2
M8H8 K,,% >'(,.' B12 Pe'+,(,
P6l')'(e.',
3
)e%&. TIB8 *T6(,l I%6
#e%, Ae.',
!
B''+ 8,/,<'(BUN *Bl66 U%e, N'(%6+e-
900/+F.l Pe'+,(, 30 +Fl
)e%&.
BUN
e')'e)' 4e)' !0 8R"
P%&%'(&) Re,l
..6lFl
%e,(''
,(,&120 .+C Le>el )e%&. %e,('' 90 ..6lFl
5
A"P B'l'%&4'
7
,(,& 10 .+C Pe'+,(, le>el
K6le)(,)')
'%e
P%&%'&) K6le)(,)')
''%e USG A46.e O4)(%&)' 4'l'e% /%'.e% Le>el TSH T3 TSH .e&%& 4e4,)
K6le)(,)') H'/e%('%6'').e
T34e4,)
.e'+,( TSH .e'+,( T3
P%&%'(&) E6%'
H'/6('%6'').e
?
8he)( R,'6+%,/h
4e4,) .e&%& L'.,e6/,('
H6+'
P%&%'(&)
.e',)('&.
l./h6.,
.,l'+,)'
H. PENATALAKSANAAN
P,, +,(,l ,+ (e%+ee%,l'),)' , (e%,' h,./'% ' )el&%&h (&4&h /,)'e )e4,', (e(,/ ,l,. e,,, (&4&h ,+ '+' , .e+h',%' &,%, /,,)$ H',%' 6)&.)' ,l6h6l , .,,, ,+ /e,)$ Pe++&,, .e(h6l )e<,%, (6/',l ,/,( .e'.4&l, )e),)' '+' .el,l&' /e%),%,, %e)e/(6% TPR 6)')e/(6% , ,/,( .ee, (e%,', +,(,l$ Pe,(,l,),,, /%&%'(&) ),+,( 4e%+,(&+ /,, /ee4,4 %,), +,(,l '(& )e'%'$ Se.e(,%, /e.e%'),, &(& .e<,%' /ee4,4 /%&%'(&) 'l,&, (e%,/,( 4e4e%,/, <,%, &(& .e+,(,)' %,), +,(,l )eh'++, .e'.4&l, /e%,),, le+, /,, /ee%'(, ,'(&: 1$ Pe,(,l,),,, )e<,%, .e') : ,$ Pe+64,(, (6/'<,l: 1- L6)'6 <,l,.'e$ L6)'6 '' (', ,/,( '+&,, /,, &l'( ,+ e%'+ , .e.'l'' 4,(,), =,(& ,l,. /e.,,',, ,%e, .e+,&+ /he6l)$ 2- L6)'6 .e(h6lF<,./h6% ,+ 4e%&+)' &(& .e.4e%', )e),)' '+'$ 3- Pe.,,', e..6l'e( ,+ (e%,(&% (e%&(,., ', &l'( e%'+$ !- K6%('6)(e%6' (6/'<,l )e,+ &(& /e%'6e =,(& ,+ /ee$ K6%('6)(e%6' )e<,%, (6/',l .,&/& )')(e.'
A('h')(,.'
,+
(',
.e+,&+
/ee,+
.e.'l''
,('/%&%'(&)$ A('h')(,.' /ee,+ ,/,( '+&,, ,%e, ee /ee,+, (e%)e4&( !- Th,l'6.'e (e%4&(' ,./&h .e+,(,)' /%&%'+6 6&l,% , 4e4e%,/, e') /%&%'(&) %6'$ Se<,%, %'+,) 64,(64,( ,+ 4ee%, )e<,%, /e%'e% ,(,%, l,' ,(,+6') H1 ,+6') H3 ,(,+6') SP ,(,+6') TRP#1 ,+6') 8B1 ,(,+6') PAR2$ Se.e(,%, ,+ 4ee%, )e<,%, )e(%,l ,,l,h +,4,/e(' *&(& +,(,le&%6/,('- (,l'6.'( *.e)&/%e)' /e%),%,,- .'%(,,/' 'h'4'(6% &/(,e )e%6(6' , 6/'6' .'& ,(,+6') ,(,& ,+6') ,//, *B&%(6 G 2002$ Pe,(,l,),,, )e<,%, e/e%,=,(, : U/,, l,' ,+ 4e%+&, &(& .e+h',%' /%&%'(&) ',(,%,, .e,)6'l,(,)' ', ,/,( .e'.4&l, %,), +,(,l *.'),l, K,e' ,l<6h6l .,,, /e,)-$ ;', e4&(&h, &(& .e++,%& (', (e%(,h,, .,, +6)6 ,(,& +,%& ,%e, ,+ 4e%),+&(, e+, (el,/, (,+,$ U(& +,(,l %'+, e+, /ee4,4 ,+ (', .e.4,h,,, )e/e%(' &l'( e%'+ ,/,( 'l,&, /e,+,, )e'%' 4e%&/,: ,$ Me+6le), /ele.4,4 &l'( 4e%&l,+ ,l' )e/,,+ h,%' , )e+e%, )e(el,h 4$ <$ $ e$
.,'$ M,' %e,. e+, ,'% h,+,( )&,.)&,. && T', .,' (e%l,l& )e%'+ e+, ,'% 4e%,,% ,/6%'( ('++'$$ K,.,% ('&% h,%&) 4e%)'h )e& , le.4,4 Me+e,, /,,', ,+ (', .e+'%'(,)' &l'( )e/e%(' ,(& , )&(%,
.e+h',%' 4,h, =6l )e%(, 4,h, )'(e)') ,+ (', .ee%,/ e%'+,($ $ Me+h',%' 6)&.)' ,e' ,l6h6l %e./,h%e./,h ,'% /,,) , e%'+,( 4e%le4'h,$ +$ Me+h',%' h,lh,l ,+ (el,h 'e(,h&' .e%&/,, /ee4,4 +,(,l$ h$ Me,+, h'+'ee /%'4,' , l'+&+,$ '$ Me
,' el&h, )&4e(' ,+ /,l'+ )e%'+ '(e.&, /,, /,)'e e+, +,++&, &l'($ A,/& .,,e.e /%&%'(&) ,+ ,.' ,/,( ' B&& A,% Ke/e%,=,(, Pe',(%' *D6, L$ W6+ 2009- ,,l,h :
1$ Mee&, ,%e, ,+ (e%e, , .e'+,(, PH &l'( e+, <,%, .,' ,'% '+' ,(,& 6./%e) '+' e+, (&&, &(& .e&%&, )('.&l,)' e)(e%, e ,%e, l&, 2$ K6./%e) ,l,l' *.'),l, .,' e+, 4,'+ )6,- e+, (&&, &(& .e'+,(, PH &l'( 4,(& .e,)66)(%')' ?$ A('h')(,.' )e/e%(' 'eh'%,.' *Be,%l- ,+ '%e)e/, e+, (,,%, )e,(' /,, ),,( ,, ('&% .,l,. .e%&/,, 64,( ,+ ee(' &(& .e+h,)'l, ('&% ,+ e, , .ee,+,$ O4,( ,(h')(,.' 6)e,)' )e/e%(' (e%e,' *Sel,e- h,%&) '/,,' &(& .e%e,, /%&%'(&) /,, )',+ h,%',$
ASUHAN KEPERAWATAN PADA PASIEN PRURITUS KARENA DERMATITIS KONTAK ALERGEN
A. PENGKA+IAN
1$ Ie('(,) ,$ P,)'e
N,.,
: T$B
U.&%
: 0 T,h&
;e') el,.'
: L,'l,'
Pe'',
: SD
Pee%,,
: B&%&h
S(,(&) /e%,=',
: Me',h
A+,.,
: H'&
S&&
: B,l'
Al,.,(
: B%$ Ul&e), Be%,(, Ke'%' T,4,,
T,++,l .,)&
: 12 "e4%&,%' 2015
T,++,l /e+,',
: 12 "e4%&,%' 2015
S&.4e% I6%.,)'
: P,)'e
D',+6), .,)&
: De%.,('(') 6(, ,lle%+e
2$ S(,(&) e)eh,(, ,$ S(,(&) Ke)eh,(, S,,( I'
Kel&h, &(,.,: G,(,l ' )el&%&h (&4&h$
Al,), .,)& R&.,h S,'( , /e%,l,, /e,'( ),,( '': Kl'e ,(,+ e+, el&h, +,(,l+,(,l /,, )el&%&h (&4&h ')e%(,' %,)h$ P,, 4,+', l&(&( /,)'e (e%,/,( le)' ,+ ','4,(, ,%e, +,%&, ,+ 6('& , e%,)$ P,)'e .e+,(,, 4,h=, +,(,l+,(,l .&<&l )e, 1 4&l, ,+ l,l& )e, /,)'e .e++&,, ),4& .,' e+, .e%e ,+ 4e%4e,$ P,)'e )e4el&., (', /e%,h .e.e%'),, +,(,l, ,%e, .e+,++,/ 4,h=, +,(,l ,, )e+e%, )e.4&h$ D,l,. h,l '' /,)'e .e+,(,, 4,h=, '(e)'(,) +,(,l .e'+,( /,, .,l,. h,%' , +,(,l (', (e%,), ),,( 4ee%,$ Se.e, (e%,/,( le)' ,'4,( +,%&, /,)'e ,h'%, .e.e%'),, +,(,l, e %&.,h ),'($
4$ S(,(&) Ke)eh,(, M,), L,l&
Pe,'( ,+ /e%,h ',l,.' P,)'e .e+,(,, (', /e%,h +,(,l+,(,l )e4el&.,$
R'=,,( ,le%+' P,)'e )e4el&., (', /e%,h .e+,l,.' %'=,,( ,le%+'$
3$ R'=,,( Pe,'( Kel&,%+,: P,)'e .e+,(,, (', ,, ,+ .e.'l'' %'=,,( /e,'( .e&l,% )e/e%(' A)., HI# , He/,('(')$ !$ R'=,,( /e+64,(, ,(,& (e%/,/,% ,( P,)'e .e+,(,, (', /e%,h .e.e%'),, , .e+64,(' +,(,l, ,%e, .e+,++,/ 4,h=, +,(,l ,, )e+e%, )e.4&h , /,)'e .e+,(,, 4,h=,
+,(,l+,(,l .&<&l )e, 1 4&l, ,+ l,l& )e, /,)'e .e++&,, ),4& .,' e+, .e%e ,+ 4e%4e, 5$ P6l, "&+)'6,l G6%6 ,$ Pe.el'h,%,, , /e%)e/)' (e%h,,/ e)eh,(,: P,)'e .e+,(,, (', /e%,h .'&. 64,( )e4,+,' 4e(& /e,+,, (e%h,,/ /e,'(, .,&/& e 6(e% &(& .e+6)&l(,)', +,(,l,$ P,)'e .e+,(,, (', .e+e(,h&' /ee4,4 )/e)'' ,%' /e,'( ,+ ',l,.',$ D,l,. h,l .e+h,,/' /e,'( /,)'e , el&,%+, ,%,+ 4e%6)&l(,)' e+, (e,+, e)eh,(, , le4'h )e%'+ /e%+' e 4,l', &(& .eele),', .,),l,h e)eh,(, ,+ 'h,,/' ,.& /,)'e (', .e+e(,h&' <,%, .e+,(,)' ,+,% %,), +,(,l, 4e%&%,+$ P,)'e &+, 4'++&+ ),,( .el'h,( 4e4e%,/, 4,+', &l'(, 4e%=,%, e.e%,h,$ Masa(a% k,ra-ata! D#$s$!s$ P!gta%&a!
4$ N&(%')' ,(,& .e(,46l': P,)'e .e+,(,, /6l, .,, /,)'e 4,' /,)'e ,/,( .e+h,4'), 1 /6%)' .,,, 6%,+ e=,), )e4,, 23 ,l' )eh,%' , /,)'e ,/,( .e+h,4'), ,'% &%,+ le4'h +el,) /e%h,%' ,(,& )e'(,% 1500.lFh,%'$ <$ P6l, el'.',)': P,)'e .e+,(,, BAB 1@ )eh,%' e+, 6)')(e)' le.4e =,%, &'+ e<6l,(, , /,)'e .e+,(,, BAK 5@ Fh,%' e+, 6)')(e)' =,%,, &'+ ,%,h *- e%' *-$ $ P6l, ,('>'(,) , l,('h, P,)'e .e+,(,, (', .e+,l,.' +,++&, ,('>'(,)$ P,)'e )eh,%'h,%' .e,l,, ,('>'(,) )e4,+,' 4&%&h '.&l,' ,%' /&&l 0?$00 WITA 4e%')('%,h,( )el,., 30 .e'( ,%' /&&l 12$00 WITA , e.4,l' e %&.,h /&&l 17$00 WITA , /,)'e .e+,(,, ),,( ', 4ee%, *.el,l&, ,('>'(,)- %,), +,(,l, (', (e%,),$
e$ P6l, ('&% , ')('%,h,(: P,)'e .e+,(,, /,, ),,( ,('>'(,), 4e%&%,+ *.,l,. h,%'- /,)'e .e%,), 4,h=, +,(,l /,, &l'(, .e.'l'' '(e)'(,) ,+ .e'+,($ Masa(a% k,ra-ata! ga!g&a! rasa !)a*a!
$ P6l, 6+'('/e%)e/(&,l P,)'e .e+,(,, (', .e.''' .,),l,h /,, /,<, 'e%,, )e/e%(' /e%,4,, /e+h'& /e+e<,/ /e+l'h,(, , /ee+,%, /,)'e$ +$ P6l, /e%)e/)' '%'F6)e/ '%' 8'(%, '%'
: /,)'e .e+,(,, .e&,' )e.&, 4,+', (&4&h /,)'e (e%&(,., 4,+', %,.4&( ,+ h'(,.$ N,.& )e.e, /,)'e .e+,l,.' +,(,l+,(,l ', .e%,), e),l ),,( .el'h,( &l'(, ,+ e.e%,h, (e%&(,., 4,+', ,+ (e%el&/,) ,%e, '+,%&$
Ie('(,)
: /,)'e .e+e,l e+, el,) '%', '.,, / ,)'e ('++,l )e%(, .e+e,l )e(',/ ,++6(, el&,%+,,$
Pe%,
: /,)'e .e+,(,, 4,h=, ,l,. el&,%+, ', 4e%/e%, )e4,+,' e/,l, %&.,h (,++, ,+ .e.'./' .e+,6.' , .e,,h' el&,%+,$ N,.& ,l,. .,),%,,( /,)'e 4e%/e%, )e4,+,' ,++6(, 4,,% ,+ <&&/ ,(' (e%&(,., ,l,. .e+h,'%' %,/,($
Ie,l '%'
: /,)'e )e./,( 4e%
H,%+, '%'
: /,)'e .e+,(,, .,l& e+, /e,'(, )eh'++, /,)'e )el,l& .e.,,' e.e, /,,+ &(& .e&(&/' &l'(,$
Masa(a% k,ra-ata! ga!gg&a! /$tra t&'&%
h$ P6l, )e)&,l , %e/%6&)' P,)'e .e+,(,, )&,h .e',h , 4e%e') el,.' l,'l,'$ D,l,. h,l '' /,)'e ',&+e%,h' 2 ,, ,l,. /e%',h,,$ P,)'e .e+,(,, (', /e%,h .e+,l,.' /e,'( /,, 6%+, %e/%6&)' .'),l, +,(,l h'++, &%' 4e%=,%, (', 6%.,l$ '$ P6l, /e%,h&4&+,
P,)'e .e+,(,, )e4el&. , )e)&,h ),'( h&4&+, e+, el&,%+,, 4,'$ Kel&,%+, .e&&+ /,)'e (e%&(,., ,l,. /ee.4&h, e (e,+, e)eh,(,$ $ P6l, .,,e.e 6/'+ )(%e)) P,)'e .e+,(,, ', ,/,( .e+,l'h, .,),l,h ,+ 'h,,/', , ),,( /,)'e (', ,., /,)'e .,./& &(& .e+,(,)' e(',,.,, (e%)e4&($ D,l,. h,l el&h,, ),,( '' /,)'e (', .e+,l,.' )(%e)) /)'6l6+') ,+ 4e%,%(' =,l,&/& ', .e%,), (', ,., e+, +,(,l+,(,l ,+ ',l,.',$ $ P6l, e,','l,' P,)'e .e+,(,, 4,h=, ', .e+,&( ,+,., h'& , )e.4,h,+ )e<,%, %&(' ,'(& 12@ )eh,%'$ S,,( '(,, 4e%,'(, e+, e/e%<,,, /,)'e .e.'l'' e/e%<,,, 4,h=, 4,l', ,/,( .ee.4&h, /e,'($ N,.& 4e%,'(, e+, e/e%<,,, ,+ ,/,( .e++,++& e)eh,(,, .'),l, l,%,+, .e.6(6+ %,.4&( , && )el,., ),'( /,)'e , el&,%+,, <&&/ /e%<,, ,, (e(,/' 4el&. /e%,h .ee%,/, l,%,+, (e%)e4&( )el,., ', +,(,l+,(,l$
$ Pe+,', 7 <'%' le)' &l'( ,- P,)'e +,(,l+,(,l /,, )el&%&h (&4&h , (e%,/,( %,)h$ P,, 4,+', l&(&( /,)'e (e%,/,( le)' ,+ ','4,(, ,%e, +,%&, ,+ 6('& , e%,)$ 4- P,)'e .e+,(,, (', .ee%'(, ,le%+' ,)., )e4el&.,$ <- P,)'e .e+,(,, 4,h=, +,(,l+,(,l .&<&l )e, 1 4&l, ,+ l,l& )e, /,)'e .e++&,, ),4& .,' e+, .e%e ,+ 4e%4e, )eh'++, /,)'e (e%,/,( 4'(' e.e%,h, /,, &l'(,$ - P,)'e .e+,(,, (e%,' 4'('4'(' e.e%,h, , %,), +,(,l /,, &l'(,$ P,)'e (', (,h, e+, +,(,l, )eh'++, /,)'e .e++,%&+,%& &l'(, )eh'++, (e%,/,( le)' /,, l&(&(,$ e- Le)' /,)'e (e%)e4&( .&<&l ,'4,( +,%&, ,+ (e%l,l& 6('& , e%,) - P,)'e .e+,(,, )e4el&., .e++&,, ),4& e+, .e%e ,+ 4e%4e, )e, 1 4&l, ,+ l,l&$
+- P,)'e .e+,(,, 4ee%, ' 4,=,h /,/,%, )',% .,(,h,%' (e(,/' /,)'e (', /e%,h +,(,l+,(,l /,, &l'(,$ P,)'e &+, .e+,(,, )e, .e++,(' .e%e ),4& ,+ 4e%4e, )e, 1 4&l, ,+ l,l& /,)'e .e,' +,(,l+,(,l /,, (&4&h,$
7$ Pe.e%'),, ',+6)(' ,- H'(&+ ,%,h le+,/ *8B8 4- K,,% >'(,.' B12 )e%&. <- TIB8 *T6(,l I%6 B''+ 8,/,<'(- BUN *Bl66 U%e, N'(%6+e- )e%&. %e,('' e- A"P B'l'%&4' '%e ''%e - USG A46.e +- Le>el TSH T34e4,) h- 8he)( R,'6+%,/h
B. DIAGNOSA KEPERAWATAN 0. A!a($s$s Data NO.
DATA
INTERPRETASI
MASALAH KEPERAWATAN
1$
DS:
P,)'e
.e+el&h
+,(,l , '(e)'(,) +,(,l 4e%(,.4,h ' .,l,. h,%'$
P,)'e .e+,(,, )el,l&
.e++,%&
Te%/,/,% 4,h, ,lle%+e *),4& .,'Re,)' '.&6l6+': ,lle%+e (e%',( e+, /%6(e' .e.4e(& ,('+e le+,/ A('+e '(,+,/ , '/%6)e) 6leh .,%6,+ , )el L,+e%h,)
4,+', ,+ +,(,l$
P,)'e .e+,(,, ',
+,(,l
D'/%e)e(,)e, 6leh )el T Sel T 4e%'e%e)',)' .e.4e(& )el T ee(6% , (e%)e)'('),)' )ee<,%, )/e)'' , )el .e.6%' Te%)e4,% e )'%&l,)' ,4e4,) )e)'('>'(,) S('.&l,)' Me%,+),+ &&+ e/'e%.') ),%, ,' Il,.,)' Scratch K6%(e) )el reflex *%ele) , )e%e4%' /ele/,), ),., ' )el&%&h &l'( e,( /e%<,4,+, &<('6 ),%, e%.6e/'e%.,l ('/e 8 (, h')(,.'e Te%/,/,% .e./e%)e/)', .e++,%&6leh ,lle%+e &&+ e.4,l' ),%, (e%.'el',)' +,(,l
Kr&saka! I!tgr$tas K&($t
.e++,%& e+, &&
,.&
(e%,,+
&+,
e+,
(el,/, Me'.4&l, %&,. , le)'
(,+,$
P,)'e .e+,(,, 4,h=, (el,h 1 4&l, .e++&,, ),4&
.,'
e+, .e% 4,%& , )e, '(& )e%'+ .e%,),,
+,(,l
,+ h'l,+ ('.4&l$
DO:
P,, ')/e)' &l'( (e%l'h,( %&,.
,,, '
(,+,
,' h'++, &l'( ,46.e$
P,, 4,+', )e'(,% l&(&(
'(e.&,
,,,
e)6%',)'
Kr&saka! I!tgr$tas K&($t
*+6%e),-$ 2$
DS:
P,)'e .e+,(,,
Ga!gg&a!
%,),
N)a*a!
+,(,l
.e'+,( .,l,.
,+ ' h,%'
.ee4,4, )&l'( ('&%$
P,)'e .e+,(,, (', .,./& &(&
K6%(e) )e%e4%' Ga!gg&a! Rasa N)a*a! .e./e%)e/)', +,(,l
Rasa
%el,)$
DO:
P,)'e
(e%,,+
(,./,
.e%'('h
,%e,
le)'
/,,
4,+', l&(&($
P,)'e
(,./,
+el'),h
,%e,
/%&%'(&)
,+
'%,),,,$
3$
DS:
P,)'e .e+,(,,
Ga!gg&a!
.,l& ,'4,( ,,,
T&'&%
4e,) le)' ,%e, +,%&,
(e%&(,.,
' 4,+', ,'$
DO:
P,)'e
(,./,
.e&(&/'
4,+',
,+
+,(,l+,(,l
e+, .e+e,,
Il,.,)' Scratch)el reflex *%ele) , /ele/,), Me'.4&l, %&,. , le)' Ga!gg&a! C$tra T&'&% h')(,.'e .e++,%&6leh &&+ ),%,
C$tra
4e%le+, /,,+$
!$
DS:
P,)'e .e+,(,,
D#$s$!s$
)el,l&
P!gta%&a!
.e++,%&
4,+', &l'( ,+ +,(,l e+, && e<&,l' /,, 4,+', ,+ (e%,), /e%'h '+,%&
e+,
(el,/, (,+,$
P,)'e .e+,(,, (el,h
.e+,l,.'
+,(,l+,(,l &%,+
)el,.,
le4'h
1
4&l, ,, (e(,/' (', .e+e%(' <,%, D#$s$!s$ P!gta%&a!
.e,+,',$
DO:
P,)'e
.e%&/,,
l&l&), SD$
1. D$ag!osa K,ra-ata!
1$ Ke%&),, '(e+%'(,) &l'( 4$ ,( '.', *4,h, ,(,& 6./6)')' ),4&- '(,,' e+, e%&),, l,/'), &l'( *le)' e%6)' , %,)h-$ 2$ G,++&, %,), ,., 4$ +e,l, (e%,'( /e,'( e%.,('(') 6(, ,lle%+e *+,(,l+,(,l ,+ (', ,/,( ',4,',- , %')'6 .&<&l, .,'e)(,)' )e&e% )e/e%(' e)6%',)' 'e)' , /e%&4,h, /'+.e(,)'- '(,,' e+, +,++&, /6l, ('&% .el,/6%, %,), +,(,l$ 3$ G,++&, <'(%, (&4&h 4$ /e,'( *e+, .e,').e l'') ,,, /%&%'(&)'(,,' e+, .e+&+,/, /e%)e/)' ,+ .e'& ,l,. /e,./'l, *.e+e,,
C. RENCANA ASUHAN KEPERAWATAN
D',+6),
T&&, , K%'(e%', h,)'l
I(e%>e)'
Ke%&),, I(e+%'(,)
Se(el,h 'l,&, (',,
NIC La'(
&l'( 4e%h&4&+,
e/e%,=,(, )el,., 3@2! ,.
Skin Surveillance
e+, ,( '.',
'h,%,/, e%&),, '(e+%'(,)
1$ I)/e)' &l'( l'h,( ,,,
*4,h, ,(,& 6./6)')'
/,)'e 4e%&%,+ e+, %'(e%',
e.e%,h, le)' e%6)'$
),4&- '(,,' e+,
h,)'l: NOC La'( Tissue Integrity Skin: Skin and
e%&),, l,/'), &l'( *le)' e%6)' , %,)h-
Mucous Membranes 1$ Le)' (e%,(,)'
R,)'6,l
1$ D,%' <,%, .e+'e)' &l'( ,/,( .e+e(,h&' /e,+,, )el,&(, ,+ ,, '4e%', e/,, /,)'e$ 2$ Me.,(,& (e%,', 'e)' &(& .e
2$ P,(,& e.&+', (e%,',
(e%,', 'e)'$
'e)' (e%&(,., /,, ,%e, ,+ (e%,' e%&),, l,/'), &l'(
NOC La'(
*le)'-$
Allergic Response Localized
1$ R&,. e.e%,h, 4e%&%,+
NIC La'( Skin Care: Topical Treatments
1$ U(& .e.''.,l, e%&),, '(e+%'(,) ,%'+, ,'4,( +,%&,$
1$ A,%, l'e &(& (', .e++,%& (e%l,l& e%,) ,(,& .e++,%& e+, .e++&,, &&+ &&+ ,%' , (el,/, (,+, *4&,
2$ Me++&,, (e%,/' ,%.,6l6+'
&&2$ L,&, (',, ele+,(' e+, .e.4e%', 64,( (6/'<,l ,(' 'l,.,)' /,, ,%e, &l'( ,+ (e%,+'( 4'l, ',&%,$ 3$ L,&, /e.,(,&, /,,
64,( ,(''l,.,)' (6/',l ,/,( .e+&%,+' (e%,', /e%,,+, /,, &l'( 3$ A+,% ,/,( .e+e(,h&' (,,(,, ,=,l 4'l, (e%,' le)' %&,. e.4,l' )eh'++, ,/,( 'l,&, /e,(,l,),,, e+, )e+e%,$
&l'( )e<,%, 4e%,l,$ G,++&, %,), ,.,
Se(el,h 'l,&, (',,
NIC La'(
4e%h&4&+, e+,
e/e%,=,(, )el,., 3@2! ,.
!ruritus Management
+e,l, (e%,'( /e,'(
'h,%,/, ,/,( .e'+,(,
e%.,('(') 6(,
%,), ,., /,, /,)'e e+,
*)e/e%(' 6(, e%.,('(')
,le%+e *+,(,l+,(,l
%'(e%', h,)'l:
)')(e.' /e+64,(,-$
,+ (', ,/,(
NOC La'(
',4,',- , %')'6
Discomort Level 1$ G,(,l 4e%&%,+ *+,(,l ,/,(
.&<&l, .,'e)(,)' )e&e% *)e/e%('
',4,', /,, .,l,. h,%'-
1$ Te(&, /ee4,4 ,%' /%&%'(&)
/ee4,4 )eh'++, '/e%l&, /ee(&, /ee4,4 ,+ /,)(' ,%' /%&%&'(&) (e%)e4&( ,+,% ,/,( .e.4e%', /e,+,, ,+ (e/,($ 2$ Me+h',%' ('.4&l, e.4,l'
2$ Be%'(,h& /,)'e &(&
e)6%',)' 'e)' ,
.e+h',%' /e++&,, ),4&
/e%&4,h, /'+.e(,)'-
,+ (el,h '+&,, (e%,h'%
'(,,' e+,
,l', *,+ (el,h .e'.4&l,
+,++&, /6l, ('&%
1$ P%&%'(&) ','4,(, 6leh 4e%4,+,'
%e,)' +,(,l3$ A/l',)', /e,++,F /e,h,
%,), +,(,l$
3$ Pe,++, ,/,( .e.4,(,)'
.el,/6%, %,), +,(,l$
le+, ,(,& )'& )el,., ('&%$ !$ Be%', (e%,/' ,('/%&%'(&) (6/',l )e)&,' '',)'$ D, 4e%', 64,( 6%,l ,('h')(,.' )e)&,' '',)'$ 5$ I)(%&)', /,)'e &(& .e++&,, (el,/, (,+, &(& .e++6)6 ,%e, ,+ +,(,l ,(,& .ee/'( &&+ &l'( )e<,%,
e'+', &(& .e++,%& /,, ),,( /,)'e (e%('&%$ !$ Te%,/' ,('/%&%'(&) , ,('h')(,.' ,/,( .e++&%,+' %,), +,(,l /,, /,)'e$ 5$ De+, .e++&,, (el,/, (,+, &(& .e++,%& &(& .e
le.4&( ,(,%, e./6l , (el&& &(& .e%e,, +,(,l$
G,++&, <'(%, (&4&h
Se(el,h 'l,&, (',,
NIC La'(
4e%h&4&+, e+,
e/e%,=,(, )el,., 2@2! ,.
"ody Image In#ancement
/e,'( *e+,
'h,%,/, ,/,( .e'+,(,
.e,').e l'')
<'(%, (&4&h /,)'e e+, %'(e%',
*.e+h',%' 6(, .,(,
,,, /%&%'(&)-
h,)'l:
&<,/, .e%e,h, '%' )e'%'-
'(,,' e+,
NOC La'(
.e+&+,/,
"ody Image 1$ P,)'e ,/,( .ee)&,',
/e%)e/)' ,+ .e
1$ K,' ,,, +,++&, <'(%, (&4&h
1$ G,++&, <'(%, '%' ,, .ee%(,' )e(',/ /e,'( ,(,& e,,, ,+ (,./, ,(, 4,+' /,)'e e), 6%,+ (e%h,,/ '%', 4e%/e+,%&h (e%h,,/ 6)e/ '%' 2$ P,)'e .e.4&(&h, %&,+ &(&
2$ Be%', e)e./,(, e/,,
'e+,%, , '/,h,.'
'%' e+, /e%&4,h,
/,)'e &(& .e+&+,/,
.e+e,' /e%,),,, (e%h,,/
6')' */e,./'l,-
/e%,),, .e+e,' +,++&&,
+,++&, <'(%, (&4&h ,+ ',l,.'
(e(,+ (&4&h ''>'&
(&4&h,$
<'(%, (&4&h ,+ ',l,.'$
,(', /e%,=,( ,/,( .e+e(,h&'
,l,. /e,./'l,
)e<,%, le4'h el,) (e(,+
*.e+e,,
.,),l,h,$
/,,+ , 4,& le+, /,,+- &(& .e&(&/' 4,+', &l'( ,+ %&,.$
3$ A+,% ,/,( .e+&%,+' /e%)e/)' 3$ B,(& l'e ,l,.
e+,(' l'e (e(,+ '%',$
.e+e.4,+, e.,./&, &(& .e'l,' '%' , .e+e,l' .,),l,h,$ !$ B,(& , .6('>,)' l'e &(& 4e%,,/(,)' e+, 6')', ),,( '' *.'),l, e+, .e.4e4,), l'e &(& .e.'l'h /,,', &(& .e&(&/' &l'(, ,+ %&,. ,, (e(,/' (e(,/ .6('>,)' l'e ,+,% (', .e%,), .,l& , h,%+, '%' %e,h ,%e, /%&%'(&)-$
!$ A+,% .e'+,(, e'+', l'e &(& 4e%,,/(,)' )eh'++, ,/,( .e.&l'h, )'(&,)'$
De')'e)' /e+e(,h&,
Se(el,h 'l,&, (',,
NIC La'(
4e%h&4&+, e+,
e/e%,=,(, )el,., 2@2! ,.
Teac#ing: Disease !rocess
&%,+ /,,,
'h,%,/, ,/,( .e'+,(,
'6%.,)' ,
/e.,h,., .e+e,' +,++&,
e(e%4,(,), 6+'('
,+ ',l,.' e+, %'(e%',
*l&l&), SD- '(,,'
h,)'l:
e+,
NOC La'(
.e+&+,/,
$no%ledge: Disease !rocess 1$ P,)'e /,h,. ,,
.,),l,h *, (', .e.,h,.' <,%, .e,+,' /%&%'(&)-
+,++&, ,+ ',l,.'$ 2$ P,)'e /,h,. .e+e,' <,%, &(& .e,+,' , .e
1$ K,' /e.,h,., l'e .e+e,' +,++&, ,+ ',l,.'$
1$ D,/,( .e+e(,h&' ('+,( /e.,h,., , ,/,( .e.4e%', /eel,), .e+e,' +,++&, ,+ ',l,.' 6leh /,)'e 2$ Pe.,/,%, .e+e,' /e%&%'(&)
2$ ;el,), /,, /,)'e .e+e,'
,, .e,.4,h =,=,), /,)'e
+,++&, /%&%'(&) )e<,%, )/e)''
)eh'++, ,l,. /e,(,l,),,,,
*e('6l6+' ,l,. h,l '' ,'
/,)'e .e,' le4'h /,h,.$
,%e, ),4& ,+ '+&,,, (,, , +e,l, /,(6')'6l6+' 4e)e%(, /e,(,l,),,,, *)e/e%(' /e++&,, (e%,/' ,('/%&%'&) , ,('h')(,.'3$ D')&)', e+, /,)'e .e+e,' /e
3$ Pe
D. IMLPLEMENTASI
I./le.e(,)' 'l,&, 4e%,),%, /,, h,)'l ,,.e), ',+6)e e/e%,=,(, ,+ '(e+,, , (&&, ,+ '+' '<,/,'$ N,.& ,/,4'l, ' ,l,. /el,),,,, (e%,' /e%&4,h, 6')' /,)'e .,, ,, 'l,&, ,,l')') ,(, )&4e(' , 64e(' e.4,l' )e%(, ')&)& %e<,, ,)&h, e/e%,=,(, )el,&(, )eh'++, './le.e(,)' ,+ 'l,&, ,/,( 4e%)',( 6./%ehe)' , .e<,/,' (&&,$
E. E2ALUASI
,$ Ke%&),, '(e+%'(,) &l'( 4e%h&4&+, e+, ,( '.', *4,h, ,(,& 6./6)')' ),4&- '(,,' e+, e%&),, l,/'), &l'( *le)' e%6)' , %,)h- S : el&,%+, /,)'e .e+,(,, .e%,h.e%,h /,, &l'( /,)'e 4e%&%,+ - O : %&,. (,./, 4e%&%,+ (', (,./, /e,.4,h, le)' - A : (&&, (e%<,/,' - P : /e%(,h,, 6')' l'e.e+,,%, /,)'e .el,&, /e.,(,&, )e<,%, 4e%,l, (e%h,,/ e.&+', %&,. .,&/& le)' ,+ ,/,( .&<&l e.4,l' 4$ G,++&, %,), ,., 4e%h&4&+, e+, +e,l, (e%,'( /e,'( e%.,('(') 6(, ,lle%+e *+,(,l+,(,l ,+ (', ,/,( ',4,',- , %e)'6 .&<&l, .,'e)(,)' )e&e% *)e/e%(' e)6%',)' 'e)' , /e%&4,h, /'+.e(,)''(,,' e+, +,++&, /6l, ('&% , .el,/6%, %,), +,(,l - S : /,)'e .e+,(,, )e),)' +,(,l .&l,' 4e%&%,+ - O: - A : (&&, (e%<,/,' - P : /e%(,h,, 6')' l'e .e+,&%, /,)'e .e+h',%' /e.,,', ),4& ,+ ,/,( .e.4&,( +,(,l .&<&l e.4,l'$ <$ G,++&, <'(%, (&4&h 4e%h&4&+, e+, /e,'( *.e,').e l'') ,,, /%&%'(&)- '(,,' e+, .e+&+,/, /e%)e/)' ,+ .e'& ,l,. /e,./'l, *.e++&,,
)e/e%(' (', .e+h',%' 6(, .,(, ),,( 4e%4'<,%, A : (&&, (e%<,/,' P : /e%(,h,, 6')' l'e
$ De')'e)' /e+e(,h&, 4e%h&4&+, e+, &%,+ /,,, '6%.,)' , e(e%4,(,), 6+'(' * l&l&), SD- '(,,' e+, .e+&+,/, .,),l,h *, (', .e.,h,.' <,%, .e,+,' /%&%'(&)- S : 1$ /,)'e .e+,(,, (el,h .e.,h,.' /ee4,4 ('.4&l, +,(,l+,(,l 2$ P,)'e .e+,(,, .e+e(,h&' <,%, /e,+, (e%h,,/ +,(,l+,(,l ,+ ',l,.', 3$ P,)'e .e+e(,h&' <,%,<,%, .e+h',%' */e
-
,le%+'- (', ('.4&l e.4,l' O : /,)'e .,./& .eel,), /ee4,4 ('.4&l, +,(,l+,(,l )e%(, .,./& .ee4&(, <,%, /e,+,, , <,%, /e
DAFTAR PUSTAKA
B%&e% S&,%(h 2000$ Buku Ajar Keperawatan Medikal – Bedah$ Te%e.,h, S&,e 8$ S.el(e%$ E')' ?$ #6l ?$ Pee%4'( B&& Ke6(e%, EG8: ;,,%(, B&%(6 G$ P,(h6/h')'6l6+ 6 /%&%'(&)$ A&)(%,l', 86lle+e 6 #e(e%',% S<'e(')() De%.,(6l6+ 8h,/(e% S<'e
