BAB 1 PENDAHULUAN
1.1 Latar Belakang
Koma miksedema merupakan salah satu penyakit kedaruratan pada kelenjar tiroid yang membahayakan jiwa akibat hipotiroidisme ekstrim. Hipotiroidisme adalah gangguan umum disertai gambaran klinis yang luas, pasien dapat asimptomatik atau dapat mengalami sakit berat disertai koma miksedema. Hipotiroidisme sering terjadi pada wanita dan insidennya meningkat sesuai bertambahnya usia. Sekitar 10%
sampai
15%
pasien
lansia
mengalami
peningkatan
TSH
akibat
hipotiroidisme dan penapisan rutin kelompok berisiko tinggi sering dilakukan pada lingkungan keperawatan keperawatan primer (Morton, 2014).
Koma miksedema biasanya dijumpai pada lansia yang mengalami hipotiroidisme dan tidak mendapat pengobatan yang adekuat. Koma miksedema lebih sering terjadi pada wanita lansia yang mengalami tiroiditis otoimun. Koma miksedema juga dapat terjadi setelah penyakit akut tiroiditis otoimun pada wanita lansia. Pajanan yang lama terhadap cuaca dingin pada individu lansia dapat menimb ulkan gangguan ini (Corwin, 2015).
Menurut data insiden pada umumnya koma miksedema mengenai individu berusia 30-50 tahun. Hipotiroidisme sering terjadi pada wanita yang memiliki jumlah prevelensi 1-2% dan meningkat dengan usia (10% dewasa > 65 tahun). Koma miksedema merupakan hipotiroidisme paling serius dan sering di picu oleh penyakit lain. Koma miksedema juga dapat meningkatkan mortalitas 100 % jika tidak diobati (Smeltzer, 2014). Angka kematian dapat diturunkan hingga kurang dari 20% dengan tirotoksikosis yang terkendali dan penanganan dini krisis tiroid.
Koma miksedema menggambarkan stadium hipotiroidisme yang paling ekstrim dan berat, di mana pasien mengalami hipotermia dan tidak sadarkan diri. Pasien dapat mengalami gejala
depresi respiratorik sehingga timbul hipoventilasi
alveolar, retensi CO2 progresif, keadaan narcosis dan koma, disertai dengan
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
kolaps kardiovaskuler dan syok. Pasien dengan koma miksedema memerlukan terapi yang agresif dan intensif. Namun, terapi yang intensif sekalipun dapat menyebabkan kematian dengan angka mortalitas yang masih tetap tinggi (Brunner & Suddarth. 2013).
Buruknya kondisi pasien dengan koma miksedema bila tidak ditangani lebih awal dapat berakibat fatal karena dalam keadaan ini dijumpai dekompensasi satu atau lebih
sistem
organ.
Berdasarkan
data-data
tersebut,
koma
miksedema
menyebabkan mortalitas yang sangat tinggi, kecurigaan dengan diagnosis yang dini dan penanganan yang adekuat prognosis biasanya akan lebih baik. Oleh karena itu diperlukan perawatan yang intensif dan pengawasan terus menerus dan juga yang terpenting adalah pemahaman yang tepat tentang kasus tersebut terutama mengenai diagnosis dan penalaksanaannya baik secara medis maupun keperawatan. Sehingga dengan pemahaman tersebut dapat lebih meningkatkan kuliatas dan kuantitas asuhan keperawatan yang diberikan kepada pasien dengan koma miksedema.
1.2 Tujuan 1.2.1 Tujuan umum
Setelah pembelajaran materi ini, mahasiswa diharapkan mampu memberikan asuhan
keperawatan
pada
pasien
dengan
kasus
miksedema
komprehensif. 1.2.2 Tujuan Khusus
1) Menjelaskan anatomi dan fisiologi kelenjar tiroid 2) Menjelaskan hormon yang terdapat pada kelenjar tiroid 3) Menjelaskan definisi koma miksedema 4) Menjelaskan etiologi koma miksedema
secara
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
BAB 2 TINJAUAN TEORITIS MEDIS
2.1 Anatomi dan Fisiologi 2.1.1 Anatomi
Gambar 2.1.1 Kelenjar Tiroid (Pustaka Sekolah, 2013)
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Kelenjar tiroid terdiri atas dua buah lobus yang terletak di sebelah kanan dan kiri trakhea, dan diikat bersama oleh secarik jaringan tiroid yang disebut istmus tiroid dan yang melintasi trakhea di sebelah depannya.
Struktur. Kelenjar tiroid terdiri atas sejumlah besar vesikel yang dibatasi oleh epitelium silinder, mendapat persediaan darah berlimpah-limpah dan yang disatukan oleh jaringan ikat. Sel itu mengeluarkan sekret cairan yang bersifat lekat yaitu koloida tiroid, yang mengandung zat snyawa yodium; zat aktif yang utama dari senyawa yodium ini adalah hormon tiroksin. Sekret ini mengisi vesikel dan dari sini berjalan ke aliran darah darah, baik langsung ataupun melalui saluran limfe (Pearce, 2014).
Hormon tiroid (thyroid hormon, TH) adalah hormon amina yang di sintesis dan dilepaskan dari kelenjar tiroid. Hormon ini dibentuk ketika satu atau dua molekul iodin disatukan dengan glikoprotein besar disebut tiroglobulin, yang disintesis di kelenjar tiroid dan mengandung asam amini tirosin. Kompleks yang mengandung iodin disebut iodotirosin. Dua iodotirosin kemudian menyatu untuk membentuk dua jenis TH yang bersirkulasi disebut T 3 dan T4. T3 dan T4 berbeda dalam jumlah total molekul iodin yang dikandungnya. Sebagian besar (90%) HT yang dilepaskan ke dalam aliran darah adalah T4 tetapi T3 secara fisiologis lebih poten (Corwin,2015).
2.1.2 Fisiologi
Sekresi tiroid diatur oleh sebuah hormon dari lobus anterior kelenjar hipofisis, yaitu oleh hormon tirotropik. Fungsi kelejar tiroid sangat erat bertalian dnegan kegiatan metabolik dalam hal pengaturan susunan kimia dalam jaringan; bekerja sebagairangsang proses oksidasi, mengatur penggunaan oksigen dan dengan
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
kekurangan sekresi mengakibatkan miksedema; proses metabolik mundur dan terdapat kecendenrungan untuk bertambah berat, gerakannya lamban, cara berpikir dan bicara lamban dan kulit menjadi tebal dan kering, rambut rontok danmenjadi jarang. Suhu badanya di bawah normal, dan denyut nadi perlahan (Pearce, 2014).
Jika gangguan berupa hipotiroid tidak segera ditangani, maka akan dapat mengakibatkan terjadinya koma miksedema yang menggambarkan hipotiroid yang paling ekstrem dan berat, dimana pasien mengalami hipotermia dan tidak sadarkan diri. Sedangkan jika hipertiroid tidak segera ditangani, maka akan dapat mengakibatkan krisis tiroid berupa hipertiroid berat yang biasanya terjadi dengan awitan mendadak dan ditandai dengan hiperpireksia, takikardia yang ekstrim serta perubahan status mental yang sering terlihat sebagai delirium (Smeltzer& Susanne, 2014).
2.2 Pengertian
Koma miksedema adalah kedaruratan yang membahayakan jiwa akibat hipotiroidisme ekstrem yang jarang terjadi. Koma miksedema biasanya terjadi pada pasien lansia selama musim dingin setelah faktor pencetus seperti stress, peajanan terhadap suhu dingin yang ektrem, atau trauma. Selain koma, komplikasi komplikasi koma miksedemaadalah efusi perikardium dan pleura, megakolon disetai ileus paralitik, dankejang. Kematian dapat terjadi jika hipoksia dan hipokapnea berat tidak terobati (Hudak, 2015).
Miksedema adalah keadaan lebih lanjut yang diakibatkan oleh karena kadar hormon tiroid dalam darah berkurang. Karena kurang aktifnya kelenjar tiroid dalam menghasilkan hormon tiroid atau hormon tiroid yang dihasilkan terlalu
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Koma Miksedema adalah keadaan yang mengancam nyawa yang ditandai oleh eksaserbasi (perburukan) semua gejala hipotiroidisme termasuk hipotermia tanpa menggigil, hipotensi, hipoglikemia, hipoventilasi, dan penurunan kesadaran yang menyebabkan koma (Corwin, 2015).
2.3 Etiologi
Koma tercetus pada pasien hipotiroid kronis karena terpajan dingin, infeksi, hipoglikemia, agen depresan pernafasan, reaksi alergi, atau stres metabolik lainnya.(Graber,dkk.2015) Koma miksedema lebih sering terjadi pada wanita lansia yang mengalami tiroiditis otoimun, pajanan yang lama terhadap cuaca dingin pada individu lansia dapat juga menimbulkan gangguan tersebut (Corwin,2015).
Faktor predisposisi menurut Hudak (2015) : a. Usia b. Stress c. Pajanan terhadap suhu dingin yang ektrem d. Trauma
2.4 Patofisiologi
Pada hipotiroidisme terjadi penurunan metabolism basal dan pasien mudah merasa kedinginan. Penggunaan oksigen, ventilasi, dan eritropoiesis akan berkurang. Berkurangnya lipolisis mendorong peningkatan berat badan dan hiperlipidemia sedangkan berkurangnya pemecahan kolesterol menjadi asam
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
plasma juga ditimbun dit imbun di kulit. Berkurangnya perubahan karoten menjadi vitamin A menyebabkan hyperkeratosis. Demikian juga berkurangnya sekresi keringat dan sebasea kulit menjadi kering dan produksi panas yang berkurang membuat kulit terasa dingin. Pasien seringkali memiliki suara parau. Menurun perangsangan jantung oleh hormone tiroid menyebabkan penurunan kontraktilitas, frekuensi denyut jantung, volume sekuncup, curah jantung dan kadang-kadang juga tekanan darah diastolic. Pada defisisiensi hormone tiroid yang nyata dapat terjadi gagal jantung, efusi pleura, dan perikard. Frekuensi pernapasan melambat dan reaksi ventilasi
terhadap
hiperkapnia
dan
hipoksia
terganggu.
Laju
filtrasi
glomerulus,aliran plasma ginjal,dan kapasitas transport tubulus berkurang. Ekskresi ginjal menurun menyebabkan retensi air dan natrium. Penurunan perangsangan otot-otot usus menyebabkan men yebabkan konstipasi. Gangguan fungsi pada otot esophagus dapat menyebabkan refluks lambung dan esofagitis. Aktivitas dan efektivitas saraf otonom akan berkurang pada hipotiroidisme. Eksitabilitas neuromuskuler juga berkurang sehingga menyebabkan gangguan fungsi sensorik, hiporefleksia, kehilangan nafsu makan, kehilangan ingatan, depresi dan kesadaran berkabut yang bahkan berlanjut menjadi koma. Selain itu pertumbuhan tulang menjadi terlambat pada anak-anak. Retardasi pertumbuhan dan kemampuan mental yang terganggu menyebabkan gambarab kreatinisme yang khas (Lang,2013).
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
pemberian obat antitiroid atau defisiensi iodin. Penyebab sekunder termasuk resistensi perifer terhadap ter hadap hormon tiroid, tumor atau infark pituitari, dan gangguan hipotalamus.
Hipotiroidisme
transien
dapat
terjadi
setelah
penghentian
pengobatan T3 dan T4 jangka panjang. panj ang. Hipotiroidisme Hipotiroidis me umumnya mempengaruhi semua sistem tubuh; rendahnya laju metabolik basal, penurunan energi metabolisme, dan pembentukan panas merupakan ciri-cirinya. Miksedema yang yang diakibatkan oleh perubahan komposisi dermis dan jaringan lain. Jaringan ikat dipisahkan oleh peningkatan jumlah protein dan mukopolisakarida; jaringan ini mengikat air, menyebabkan edema nonpitting, boogy, terutama di sekitar mata, tangan, dan kaki juga bertanggung jawab terhadap penebalan lidah dan laring dan membran mukosa faring, mengakibatkan bicara tidak jelas dan sakit tenggorok. Selain gejala-gejala klinis dari hipotiroidisme, penurunan T3 dan T4 bebas adalah temuan yang umum (Hudak & Gallo, 2015).
2.5 Manifestasi Klinis
Gambaran klinis yang ditemukan pada pasien dengan koma miksedema menurut Baughman (2013) adalah sebagai berikut : a. Gejala dini umum yang tidak spesifik b. Keletihan ekstrem c. Kulit menjadi menebal, rambut menipis dan rontok; wajah menjadi tanpa
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
e. Kulit : kasar dan kering, kemungkinan warna karotena, edema periorbital dan edema pada wajah f. Neurologis : tumpul, koma, atau kejang, kejang, refleks lambat g. Gastrointestinal : penurunan bising usus h. Endokrin : tiroid mungkin tidak dapat dipalpasi, membesar, atau berbentuk nodular i.
Hipoventilasi
j.
Penurunan fungsi mental
k. Keletihan yang berat l.
Intoleransi aktivitas
m. Hiporefleksia n. Gagal jantung dan gagal nafas
Menurut Linda (2014), manifestasi klinis koma miksedema adalah sebagai berikut: a. Kulit pucat, dengan warna kekuningan yang dihasilkan dari peningkatan deposito karoten. b. Penurunan metabolic rate ditandai dengan hipotermia, hypoventilasi, hypoxemia, hyponatremia, hipoglikemia, bradicardia, hipercolesterol, hyperlipidemia dan anemia. Output urine menurun
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Diagnosis yang ditegakkan berdasarkan indeks kecurigaan
yang tinggi.
Pemeriksaan tiroid yang mengindikasikan hipotiroidisme primer adalah : a. Peningkatan kadar hormon perangsang tiroid (TSH) (Tes Standar Emas) dan indeks tiroksin bebas yang rendah (jika hasil pemeriksaan TSH tidak definitif). b. Hiponatremia dan hipoglikemia mungkin terjadi c. EKG menunjukkan voltase rendah, interval QT memanjang, dan gelombang T datar atau invers. d. Kadar kortisol juga mungkin rendah. (Stillwell, 2013) 2.7 Penatalaksanaan Penatalaksanaan
Komplikasi hipertiroidisme yang paling serius adalah perkembangan penyakit menjadi koma miksedema dan kematian, jika hipotiroidisme tidakdiobati. Pendekatan multisistem harus digunakan dalam perawatan kedaruratan dalam kondisi
ini.
Ventilasi
mekanik
digunakan
mengendalikan
hipoventilasi,
hiperkapnea, dan henti nafas. Pemberian salin normal hipertonik dan glukosa secara intravena mengoreksi keadaan hiponatremia dan hipoglikemia. Pemberian cairan disertai terapi vasopressor dapat diperlukan untuk mengoreksi hipotensi. Terapi farmakologis meliputi pemberian hormon tiroid dan kortikosteroid. Terdapat banyak pendekatan untuk aspek penatalaksanaan medis ini. Terapi obat
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
menggunakan selimut dan kaos kaki. Alat mekanis tidak digunakan. Status neurologis dan perubahan tingkat kesadaran pasien dipantau. Dilakukan tindakan pencegahan kejang. Ketika pasien dalam keadaan koma, perawatan meliputi pencegahan komplikasi akibat aspirasi, imobilitas, kerusakan kulit, dan infeksi. Fungsi jantung dan pernafasan dibantu. Pemeberian cairan juga harus dipantau karena terdapat risiko kelebihan beban cairan. Aspek perawatan yang penting adalah mendeteksi tanda-tanda awal komplikasi. Seiring penyembuhan pasien, fokus intervensinya adalah perawatan mandiri dan penyuluhan. Tindak lanjut pasien meliputi pemeriksaan menyeluruh bagaimana hipotiroidisme berat dan bagaimana cara terbaik untuk menghindarinya agar tidak terjadi pada masa yang akan datang. Penyuluhan pasien, tindak lanjut keluarga, pelaksanaan kewaspadaan medis, dan pelibatan dukungan masyarakat mungkin diperlukan untuk pasien kompleks ini (Morton, 2014).
Beberapa penanganan pada pasien koma miksedema menurut Graber, dkk (2015) diantaranya: a. Penggantian tiroid, untuk meningkatkan kadar hormon tiroid b. Oksigen tambahan dan intubasi/ventilasi mekanis, untuk memperbaiki ventilasi/oksigenasi. c. Metode pemanasan, untuk memperbaiki ventilasi/oksigenasi. d. Kristaloid
dan
agen
vasopresor,
untuk
memperbaiki
stabililitas
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Nilai T3 dan T4
2.8 Pasien hipotiroid kronis akibat terpajan suhu dingin, infeksi, agen depresan pernafasan,
Hipotiroidisme
reaksi alergi, tiroiditis otoimun, trauma, usia,
T3 normal
: 80-160 µg/dl
T4 normal
: 4-11 µg/dl
T3 ↓
:
T4 ↓
:
WOC
gagal minum obat Koma Miksedema
Kekurangan asupan yodium
Defisiensi Iodin (-)
Gin al
Defisiensi T3 dan T4
Jantung Jantung
Tulang
Sistem pernafasan
Laju
Gastrointestinal
metabolisme Penurunan hormon
Penurunan respon
Hormon calsitonin
basal ↓ Motilitas usus ↓
ventilatorik
aldosteron
produksi panas ↓ Calsium pada jantung ↓
Calsium pada tulang ↓
saluran nafas
Retensi Na+ dan H2O
stimulasi Na+, K+ , MK : Penurunan
Edema difus dan pitting
MK : Kelebihan volume cairan
Mipopati otot
Curah jantung
atrium
otot jantung
Osteoporosis
Kelemahan diafragma
MK : Resiko Cidera
Hipoventilasi alveolus kronik
ATPase dalam semua jaringan ↓
MK : Hipotermia
MK : Konstipasi
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
BAB 3 TINJAUAN TEORITIS KEPERAWATAN
1) Pengkajian Pada pengkajian dilakukan wawancara dan pemeriksaan fisik untuk memperoleh informasi dan data yang nantinya akan digunakan sebagai dasar untuk membuat rencana asuhan keperawatan klien. a. Biodata /identitas klien meliputi: nama, umur, jenis kelamin, agama, bahasa, pekerjaan, kebangsaan, alamat, pendidikan, tanggal MRS,nomor register dan diagnosa medis. b. Keluhan utama Keluhan utama adalah keluhan yang dirasakan klien pada saat dikaji. Biasanya klien mengeluh : tampak lelah, loyo, tidak tahan dingin, daya ingat menurun, sembelit, menstruasi tidak teratur. c. Riwayat kesehatan sekarang
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
f. Kebiasaan hidup sehari-hari, seperti: 1) pola makan (misal: mengkonsumsi makanan yang kadar yodiumnya yodiumnya rendah, dan nafsu makan menurun) 2) pola tidur (misal: klien menghabiskan banyak waktu untuk tidur, sering tidur larut malam) 3) pola aktivitas (misal: klien terlalu memforsir pekerjaan sehingga sering mengeluh kelelahan). g. Pengkajian psikososial Klien sangat sulit membina hubungan sosial dengan lingkungannya, mengurung diri/bahkan mania. Klien sangat malas beraktivitas, dan ingin tidur sepanjang hari. mengkaji bagaimana konsep diri klien mencakup kelima komponen konsep diri. h. Pengkajian fungsi seksual 1. Penurunan libido 2. Impotensi, infertilitas
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Terdapat juga tanda berupa ekstermitas pucat, dingin, nadi lambat dan lemah, waktu pengisian kapiler >3 detik, tekanan darah turun, dan sianosis c. B3 (Brain) Terdapat
tanda
gejala
akibat
penurunan
metabolism
yang
menghasilkan penurunan kesadaran, depresi, letargi, somnolen, kurang berkonsentrasi, suara parau, hiporefleksia. Pengaturan panas tubuh menurun sehingga terjadinya hipotermia (26,7 oC) dan bisa terjadi kegawatan. Diagnosa koma miksedema tergantung pada gejala – gejala gejala klinis dan identifikasi faktor pencetus yang mendasari. Faktor pencetus yang paling umum adalah infeksi paru; yang lain meliputi trauma, stress, infeksi, obat – obatan seperti barbiturate, pembedahan, dan gangguan metabolic d. B4 (Bladder) Penurunan keluaran urine akibat fungsi ginjalterganggu dengan
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
d. Kelemahan berhubungan dengan e. Konstipasi berhubungan dengan penurunan motilitas motilitas saluran cerna. f. Risiko cedera berhubungan dengan perubahan tingkat kesadaran dan kekurangan volume cairan sekunder akibat gangguan bersihan air bebas
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
4) Intervensi Keperawatan
NO DIAGNOSA
1
KRITERIA HASIL
INTERVENSI
KEPERAWATAN
(NOC)
(NIC)
Hipotermia
Setelah
berhubungan terpajan yang
dengan tindakan lingkungan selama
dingin
kedinginan waktu lama)
dilakukan keperawatan 2x24
jam
atau diharapkan klien mampu: (dalam Menunjukkan termoregulasi,
Pengkajian
1. Catat nilai dasar tanda-tanda vital 2. Lakukan pemantauan jantung pada pasien
yang
Kaji gejala hipotermia
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
hangat
jika
tidak
memungkinkan menaikkan
suhu
untuk ruangan,
bahkan gunakan jaket, topi bila perlu Kolaboratif
1.
Untuk hipotermia berat bantu dengan menghangatkan tubuh
teknik suhu
inti
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
perkembangan sekuele klinis . Pengkajian Diagnostik
Tinjau
GDA
serial
untuk
mengevaluasi oksigenasi dan keseimbangan asam-basa. Penatalaksanaan Pasien
a. Berikan sesuai
oksigen
tambahan
intruksi
(untuk
penatalaksanaan pasien pada terapi ventilasi)
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
3
Penurunan jantung
curah berhubungan
Pasien
sadar
dan
berorientasi
Pemantauan Pasien
a. Pantau EKG secara kontinu
dengan bradikardia dan
TDS 90-140 mm Hg
untuk
penurunan isi sekuncup
MAP 70-105 mm Hg
disritmia
(IS)
FJ 60-100 kali/menit
berat
Haluaran ml/jam
urine atau
30 0,5-1
ml/kg/jam Denyut
mengetahui atau
bradikardia
yang
berpengaruh
adanya
buruk
dapat pada
curah jantung. Internal QT yang memanjang berkaitan
nadi
dapat dipalpasi
perifer
dengan torsade de pointes. pointes. Pantau
perubahan
segmen
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
bandingkan
berat
badan
serial, perubahan yang cepat (0,5-1 kg/hari) menunjukkan ketidakseimbangan cairan. Pengkajian Pasien
a. Kaji status kardiovaskular: catat kualitas denyut nadi perifer dan pengisian kapiler. Observasi peningkatan
adanya tekanan
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Penatalaksanaan Pasien
a. Berikan sesuai
cairan intruksi
intravena untuk
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
b.
Pantau tingkat kesadaran dengan Skala
menggunakan Koma
Glasgow.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
berat
jenis
urine.
Hiponatremia
dapat
menyebabkan
status
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
BAB 4 KASUS
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
B2 (Blood)
Terdapat penurunan curah jantung, terdapat kardiomegali TD 150/90 x/menit,nadi <60 x/menit, suhu 30,5°C, pemeriksaan laboratorium TSH <0,004µIU/ml, FT4 20µg/dl, FT3
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Titles you can't find anywhere else
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.