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Resume Isk
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Nurul Fitriyah
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PROGRAM STUDI ILMU KEPERAWATAN UNIVERSITAS JEMBER FORMAT RESUME KASUS KELOLAAN HARIAN (SABTU, 03 MEI 2014 DI INSTALASI GAWAT DARURAT) Nama Klien
: Ny. W
Umur
: 34 tahun
MRS
: 3 Mei 2015 / 09.55 WIB
ia!n"#a Me$i#
: #u#%e&t ISK
Ru'u(an $ari
: $atan! #en$iri
men!ata(an nyeri %a$a #aat +er(emih +er(emih $an tera#a %ana# S (Su!"#$%&) (Su!"#$%&)'' ) *a#ien men!ata(an #e'a( 4 hari yan! lau *a#ien men!ata(an ,arna air (en&in!nya +er,arna merah %e(at
$an (eluar #e$i(it)#e$i(it ta%i #erin! *a#ien men!ata(an +a$annya tera#a %ana# #e'a( 4 hari yan! lalu O (O!"#$%&)' (O!"#$%&)' ) (ea$aan umum lemah $en!an -S: 4 5 Ke#a$aran ("m%"# meti# $i$a $i$a%at %at(a (an n : : 130/ 130/0 0 mm! mm! N: 46/ 46/me meni nit t RR: RR: 1
6/menit S: 3 " 7(ral %ana# *a#ien tam%a( !eli#ah $an merin!i# *a#ien tam%a( lemah 8 Paliatif : nyeri #aat +er(emih * 8 Paliatif (Quality): (Quality): nyeri tera#a #e%erti ter+a(ar R (Regio): (Regio): nyeri tera#a +erat %a$a +a!ian !enital #aat +er(emih $an %a$a +a!ian #u%ra%u+i( S 8Scale 8Scale: : #(ala nyeri: #aat $ila(u(an %en!(a'ian $i I- (Time): (Time): nyeri ter'a$i #aat +er(emih $an +er(uran! #aat i#tirahat in;lama#i A (A*+%*)' Nyeri a(ut +erhu+un!an $en!an in;lama#i
i%ert i%erterm ermii +erhu+ +erhu+un! un!an an $en!an $en!an re#%"n# re#%"n# #i#temi #i#temi( ( #e(un$ #e(un$er er $ari $ari in;e(#i
P (P"-".***)'
a. 6 1: Nye Nyeri ri a(ut a(ut +erhu+u +erhu+un!a n!an n $en!an $en!an in;lam in;lama#i a#i N<:
a *a#ien terlihat rile(# + in!(at atau #(ala nyeri %a#ien +er(uran! $ari men'a$i 3 $an +ertaha% turun #am%ai hilan! & $alam +ata# n"rmal 8: 120/0 mm! N: 0)100 6/menit RR: 1)24 6/menit S: 35)35 " NI: a
Ka'i tin!(at nyeri %a#ien
+ <+#er=a#i 8 $an na$i &
7'ar(an te(ni( n"n;arma("l"!i 8na%a# $alam $an ma##a#e
$ K"la+"ra#i %em+erian anal!eti( (et"r"la& 1 am% 30 m! melalui I
+. 6 2: i%ertermi +erhu+un!an $en!an re#%"n# #i#temi( #e(un$er $ari in;e(#i N<: a Suhu %a#ien $alam +ata# n"rmal 835 0)3 50 + 7(ral han!at NI: a (a'i %eru+ahan #uhu tu+uh %a#ien + an'ur(an %a#ien men!!una(an %a(aian yan! ti%i# $an le%a# 'a(et & ("la+"ra#i %em+erian "+at anti+i"ti( $an anti%ireti(
I (I/+"/"$*%)' 1 6 1: Nyeri a(ut +erhu+un!an $en!an in;lama#i
a Men!(a'i tin!(at nyeri %a#ien $en!an ha#il * 8 Paliatif : nyeri #aat +er(emih (Quality): nyeri tera#a #e%erti ter+a(ar R (Regio): nyeri tera#a +erat %a$a +a!ian !enital #aat +er(emih $an %a$a +a!ian #u%ra%u+i( S 8Scale: #(ala nyeri: 4 (Time): nyeri ter'a$i #aat +er(emih $an +er(uran! #aat i#tirahat + $i$a%at(an : 130/0 mm! N: 46/menit RR: 1 6/menit S: 3 " & Men!a'ar(an te(ni( n"n;arma("l"!i na%a# $alam
$ K"la+"ra#i %em+erian anal!eti( : (et"r"la& 1 am% 30 m! melalui I
2 6 2: i%ertermi +erhu+un!an $en!an re#%"n# #i#temi( #e(un$er $ari
in;e(#i a Men!(a'i (a'i %eru+ahan #uhu tu+uh %a#ien $i$a%at(an ha#il #uhu tu+uh %a#ien 3 0 + Men!anan'ur(an %a#ien men!!una(an %a(aian yan! ti%i# $an le%a# 'a(et & +er("la+"ra#i %em+erian "+at anti+i"ti( &e;"ta6im 161!ram / i=
E (E*+u*%) ' * D 1' S ' %a#ien men!ata(an nyeri #e$i(it +er(uran! 'i(a $alam %"#i#i ti$ur O ' ) * 8 Paliatif : nyeri #aat +er(emih (Quality): nyeri tera#a #e%erti ter+a(ar R (Regio): nyeri tera#a +erat %a$a +a!ian !enital #aat +er(emih $an
%a$a +a!ian #u%ra%u+i( S 8Scale: #(ala nyeri: 4 (Time): nyeri ter'a$i #aat +er(emih $an +er(uran! #aat i#tirahat A ' ma#alah (e%era,atan nyeri a(ut terata#i #e+a!ian P ' >an'ut(an $an m"$i;i(a#i inter=en#i
K"la+"ra#i %em+erian (et"r"la& 1 am% 30 m! melalui I
D 2' S ' %a#ien men!ata(an ma#ih tera#a %ana# +a$annya O ' ) a(ral %a#ien %ana# Suhu %a#ien 35 A ' ma#alah (e%era,atan hi%ertermi terata#i #e+a!ian P ' >an'ut(an $an m"$i;i(a#i inter=en#i
K"la+"ra#i %em+erian anti%ireti(
ANALISA DATA N*/* $"-* T**+
3 Mei
N5
1
2014
D*$* F5#u
#:
P-5+"/
E$%5+5%
6* TTD
Nyeri a(ut
;a(t"r eti"l"!i 8+a(teri e)
/*7*%8* M"+%6*
) *a#ien men!ata(an nyeri %a$a #aat
&"li (le+#iela %r"teu#
+er(emih $an tera#a %ana# #e'a( 4 hari
#ta%hyl"&"&u#
yan! lalu ":
in=a#i (e #aluran (emih $i$a%at(an : 130/0 mm! N: 46/menit RR: 1
%ertahanan l"(al ti$a(
"
6/menit S: 3 *a#ien tam%a( !eli#ah
mam%u mela,an in;e(#i $an
merin!i# * 8 Paliatif : nyeri #aat +er(emih (Quality): nyeri tera#a #e%erti
ISK
ter+a(ar R (Regio): nyeri tera#a +erat %a$a
+a!ian
+er(emih
$an
!enital %a$a
in;lam#i $an Irita#i %a$a #aluran (emih
#aat +a!ian
nyeri a(ut
#u%ra%u+i(
S 8Scale: #(ala nyeri: #aat $ila(u(an %en!(a'ian $i I- (Time): nyeri ter'a$i #aat +er(emih $an +er(uran! #aat i#tirahat 3 Mei 2014
2
#:
i%ertermi
*a#ien
men!ata(an
+a$annya
tera#a %ana# #e'a( 4 hari yan!
;a(t"r eti"l"!i 8+a(teri e) &"li (le+#iela %r"teu# #ta%hyl"&"&u#
lalu ":
*a#ien tam%a( lemah Suhu 3 " *a#ien tam%a( lemah 7(ral %ana#
in=a#i (e #aluran (emih
%ertahanan l"(al ti$a( mam%u mela,an in;e(#i
ISK
in;lama#i $an Irita#i %a$a #aluran (emih
meran!#an! term"#tat tu+uh
M"+%6*
S 8Scale: #(ala nyeri: #aat $ila(u(an %en!(a'ian $i I- (Time): nyeri ter'a$i #aat +er(emih $an +er(uran! #aat i#tirahat 3 Mei
2
#:
i%ertermi
2014
*a#ien
men!ata(an
+a$annya
;a(t"r eti"l"!i 8+a(teri e)
M"+%6*
&"li (le+#iela %r"teu#
tera#a %ana# #e'a( 4 hari yan!
#ta%hyl"&"&u#
lalu ":
*a#ien tam%a( lemah Suhu 3 " *a#ien tam%a( lemah 7(ral %ana#
in=a#i (e #aluran (emih
%ertahanan l"(al ti$a( mam%u mela,an in;e(#i
ISK
in;lama#i $an Irita#i %a$a #aluran (emih
meran!#an! term"#tat tu+uh
%enin!(atan #uhu tu+uh
hi%ertermi
DAFTAR DIAGNOSA KEPERAWATAN
T**+
3 mei 2 014 3 mei 2014
N5
1 2
D%*5* K""-*8*$*
Nyeri a(u t + erh u+un!an $en!an in ;lama#i i%ertermi +erhu+un!an $en!an re#%"n# #i#temi( #e(un$er $ari in;e(#i
N*/* $"-* 6* $*6* $** M"+%6* M"+%6*
TINDAKAN PERAWATAN
T**+
D%*5* #""-*8*$*
J*/
T%6*#* P"-*8*$*
N*/* "-*8*$9/*7*%8*
%enin!(atan #uhu tu+uh
hi%ertermi
DAFTAR DIAGNOSA KEPERAWATAN
T**+
3 mei 2 014 3 mei 2014
N5
1 2
D%*5* K""-*8*$*
Nyeri a(u t + erh u+un!an $en!an in ;lama#i i%ertermi +erhu+un!an $en!an re#%"n# #i#temi( #e(un$er $ari in;e(#i
N*/* $"-* 6* $*6* $** M"+%6* M"+%6*
TINDAKAN PERAWATAN
T**+
D%*5*
J*/
T%6*#* P"-*8*$*
N*/* "-*8*$9/*7*%8*
#""-*8*$*
3 mei 2014
Nyeri
a(ut 10. 00 ,i+
+erhu+un!an
a Men!(a'i tin!(at nyeri %a#ien $en!an ha#il * 8 Paliatif : nyeri #aat +er(emih (Quality): nyeri tera#a #e%erti ter+a(ar R (Regio): nyeri tera#a +erat %a$a +a!ian !enital
$en!an in;lama#i
#aat +er(emih $an %a$a +a!ian #u%ra%u+i( S 8Scale: #(ala nyeri: 4 (Time): nyeri ter'a$i #aat +er(emih $an +er(uran! #aat i#tirahat + $i$a%at(an : 130/0 mm! N: 46/menit 10.15 ,i+
10.15 ,i+ 3 mei 2024
i%ertermi
10.30 ,i+ 10. 00 ,i+
10.10 ,i+
re#%"n# #i#temi( #e(un$er $ari in;e(#i
30 m! melalui I
a Men!(a'i (a'i %eru+ahan #uhu tu+uh %a#ien $i$a%at(an ha#il #uhu tu+uh %a#ien 3 0
+erhu+un!an $en!an
RR: 1 6/menit S: 3" & Men!a'ar(an te(ni( n"n;arma("l"!i na%a# $alam $ K"la+"ra#i %em+erian anal!eti( : (et"r"la& 1 am%
+ Men!anan'ur(an %a#ien men!!una(an %a(aian yan! ti%i# $an le%a# 'a(et
10.30 ,i+
& +er("la+"ra#i %em+erian "+at anti+i"ti( &e;"ta6im 161!ram / i=
M"+%6* M"+%6*
3 mei 2014
Nyeri
a(ut 10. 00 ,i+
+erhu+un!an
a Men!(a'i tin!(at nyeri %a#ien $en!an ha#il * 8 Paliatif : nyeri #aat +er(emih (Quality): nyeri tera#a #e%erti ter+a(ar R (Regio): nyeri tera#a +erat %a$a +a!ian !enital
$en!an in;lama#i
#aat +er(emih $an %a$a +a!ian #u%ra%u+i( S 8Scale: #(ala nyeri: 4 (Time): nyeri ter'a$i #aat +er(emih $an +er(uran! #aat i#tirahat + $i$a%at(an : 130/0 mm! N: 46/menit 10.15 ,i+
10.15 ,i+ 3 mei 2024
i%ertermi
10.30 ,i+ 10. 00 ,i+
10.10 ,i+
re#%"n# #i#temi( #e(un$er $ari in;e(#i
30 m! melalui I
a Men!(a'i (a'i %eru+ahan #uhu tu+uh %a#ien $i$a%at(an ha#il #uhu tu+uh %a#ien 3 0
+erhu+un!an $en!an
RR: 1 6/menit S: 3" & Men!a'ar(an te(ni( n"n;arma("l"!i na%a# $alam $ K"la+"ra#i %em+erian anal!eti( : (et"r"la& 1 am%
+ Men!anan'ur(an %a#ien men!!una(an %a(aian yan! ti%i# $an le%a# 'a(et
10.30 ,i+
& +er("la+"ra#i %em+erian "+at anti+i"ti( &e;"ta6im 161!ram / i=
M"+%6* M"+%6*
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