LP DM TRIA

8/17/2019 LP DM TRIA

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LAPORAN PENDAHULUAN ASUHAN

KEPERAWATAN PADA PASIEN DENGAN

DIABETES MELITUS

Oleh :

D-IV Keperawatan Tingkat 2 Semester IV

NI NYOMAN TRIA SUNITA P07120214020

KEMENTERIAN KESEHATAN RI

POLITEKNIK KESEHATAN DENPASAR

JURUSAN KEPERAWATAN

TAHUN 2016


2/26

LAPORAN PEND!L!AN AS!AN KEPERA"ATAN PADA PASIEN

DEN#AN DIA$ETES %ELIT!S

I& KONSEP DASAR PEN'AKIT

A& Pengertian

Diabetes Meit!s a"aa# $ea"aa% #i&e'(i$e)i $'*%i$ "ise'tai be'ba(ai

$eai%a% )etab*i$ a$ibat (a%((!a% #*')*%a +,a%( )e%i)b!$a%

be'ba(ai $*)&i$asi $'*%i$ &a"a )ata + (i%-a+ sa'a. "a% &e)b!!# "a'a#+

"ise'tai esi &a"a )e)b'a% basais "aa) &e)e'i$saa% "e%(a%

)i$'*s$*&i$ ee/t'*% Ma%s-*e'+ 2001

Diabaetes Meit!s a"aa# se$e*)&*$ $eai%a% #ete'*(e% ,a%( "ita%"ai

*e# $e%ai$a% $a"a' (!$*sa "aa) "a'a# ata! #i&e'(i$e)ia 3'!%%e'

"a% S!""a't#+ 2000

Diabetes Meit!s a"aa# (a%((!a% )etab*is)e se/a'a (e%etis "a% $i%is

te')as!$ #ete'*(e% "e%(a% )a%i.estasi be'!&a #ia%(%,a t*e'a%si

$a'b*#i"'at P'i/e+ 2000

Da'i bebe'a&a "e.i%isi "iatas te%ta%( DM "a&at "ia)bi $esi)&!a% ba#a

DM a"aa# s!at! &e%,a$it ,a%( "isebab$a% *e# (a%((!a% #*')*%a

"aa) #a i%i a"aa# #*')*% i%s!i% ,a%( "i#asi$a% *e# &a%$'eas "a%

)eibat$a% )etab*is)e $a'b*#i"'at "i)a%a sese*'a%( ti"a$ "a&at

)e)&'*"!$si /!$!& i%s!i% ata! ti"a$ "a&at )e%((!%a$a% i%s!i% ,a%(

"i&'*"!$si "e%(a bai$+ $a'e%a &'*ses a!t*i))!%e+ "i&e%(a'!#i se/a'a

(e%eti/ "e%(a% (e-aa ,a%( &a"a a$#i'%,a )e%!-! ta#a& &e'!sa$a%

i)!%**(i se5se ,a%( )e)&'*"!$si i%s!i%


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$& Anat(mi )an *isi(l(gi

ANATO%I DAN +ISIOLO#I

SISTE% ENDOKRIN


4/26


5/26

a'i%( A"a&!% .!%(si $ee%-a' ti'*$si% a"aa# )e%(at!' &e't!$a'a%

)etab*is)e "aa) t!b!# "a)% )e%(at!' &e't!)b!#a% Seai% it!

-!(a $ee%-a' ti'*i" )e)&!%,ai .!%(si

a 3e$e'-a seba(ai &e'a%(sa%( $e'-a *$si"asi

b Me%(at!' &e%((!%aa% *$si"asi

/ Me%(at!' &e%(e!a'a% $a'b*%"i*$si"a

" Pe%(at!'a% s!s!%a% $i)ia "a'a#+ -a'i%(a%

4 Kee%-a' Ti)!s

Kee%-a' i%i "i )e"iasti%!) "i bea$a%( *s ste'%!) Kee%-a' ti)!s

te'eta$ "i "aa) t#*'a$ ,a%( te'"i'i "a'i 2 *b!s A"a&!% .!%(si "a'i

$ee%-a' ti)!s a"aa#

a Me%(a$ti.$a% &e't!)b!#a% ba"a%

b Me%(!'a%(i a$ti.itas $ee%-a' $ea)i%

= Kee%-a' A"'e%a

Kee%-a' a"'e%a a"a 2 ba(ia% ,ait!

a 3a(ia% !a' ,a%( be'a'%a $e$!%i%(a% ,a%( )e%(#asi$a% $*'tis*

b "iseb!t $*'te$s

/ 3a(ia% )e"!a ,a%( )e%(#asi$a% a"'e%ai% e&i%e&'i% "a% %*%

" a"'e%ai% %*% e&i%e&'i%

N*% a"'e%ai% "a&at )e%ai$$a% te$a%a% "a'a# "e%(a% /a'a

)e'a%(sa%( se'ab!t *t*t "i "aa) "i%"i%( &e)b!!# "a'a# !%t!$

be'$*%t'a$si+ a"'e%ai% )e)ba%t! )etab*is)e $a'b*#i"'at "e%(a%

/a'a )e%a)ba# &e%(e!a'a% (!$*sa "aa) #ati A"a&!% .!%(i

$ee%-a' a"'e%a ba(ia% $*'te$s a"aa#

a Me%(at!' $esei)ba%(a% ai'+ ee$t*it+ "a% (a'a) b Me)&e%(a'!#i )etab*is)e #i"'at a'a%( "a% &'*tei%

/ Me)&e%(a'!#i a$ti.itas -a'i%(a% i).*i"

Da% .!%(si $ee%-a' a"'e%a ba(ia% )e"!a a"aa#

" >as* $*%t'i$si &e)b!!# "a'a# &e'i.e'

e Rea$sasi b'*%$!s

6 Pa%$'eas


6/26

Te'"a&at "i bea$a%( a)b!%( "i "e&a% e'teb'a !)bais 1 "a% 2

te'"i'i "a'i se5 se aa "a% beta Se aa )e%(#asi$a% #*')*%

(!$a(*% "a% se beta )e%(#asi$a% #*')*% i%s!i% H*')*% ,a%( "i

(!%a$a% !%t!$ &e%(*bata% "iabetes a"aa# #*')*% i%s!i% ,a%(

)e'!&a$a% seb!a# &'*tei% ,a%( t!'!t "i /e'%a$a% *e# e%8i)

&e%/e'%aa% &'*tei%

;!%(si #*')*% i%s!i% a"aa# )e%(e%"ai$a% $a"a' (!$*sa "a% bia

"i(!%a$a% seba(ai &e%(*bata% a"aa# )e)&e'bai$i se t!b!# !%t!$

)e%(a)ati "a% &e%((!%aa% (!$*sa "a) e)a$ Seai% it! -!(a

te'"a&at &!a! a%(e'#a%s ,a%( be'be%t!$ *a ,a%( te'seba' $e

se!'!# t!b!# &a%$'eas "a% te'ba%,a$ &a"a ba(ia% $e"!a &a%$'eas

;!%(si "a'i &!a! a%(e'#a%s a"aa# seba(ai !%it se$'esi "aa)

&e%(e!a'a% #*)e*stasti$ %!t'isi+ )e%(#a)bat se$'esi i%s!i%

(i$*(e% "a% &*ii&e&ti"a &a%/'eas se'ta )e%(#a)bat se$'esi (i$*(e%

Seai% it! -!(a &a%$'eas seba(ai te)&at /a"a%(a% ba(i t!b!# "a%

&e%((!%aa% (!$*sa

7 Kee%-a' *a'i$a

Te'"a&at &a"a a%ita "a% te'eta$ &a"a "isa)&i%( $a%a% "a% $i'i

!te'!s "a% )e%(#asi$a% #*')*% este'*(e% "a% &'*(este'*%+ #*')*%

i%i)e)&e%(a'!#i !te'!s "a% )e)be'i$a% si.at $ea%itaa%

? Kee%-a' Testi$a

Te'"a&at &a"a &'ia te'eta$ &a"a s$'*t!) "a% )e%(#asi$a% #*')*%e

test*ste'*% ,a%( )e)&e%(a'!#i &e%(e!a'a% s&e')a

,& Eti(l(gi

1 Diabetes Meit!s ti&e 1@ IDDM I%s!i% De&e%"e%t Diabetes Meit!sDM ti&e 1 "ita%"ai *e# &e%(#a%/!'a% se5se beta &a%$'eas .a/t*'

(e%eti$ i)!%**(i "a% )!%($i% &!a i%($!%(a% i'!s "i&e'$i'a$a%

t!'!t )e%i)b!$a% "ist'!$si se beta

a ;a$t*' (e%eti/

Pe%"e'ita DM ti&e I )ea'isi $e/e%"e'!%(a% (e%eti$ $ea'a# DM

ti&e I+ $e/e%"e'!%(a% i%i "ite)!$a% &a"a i%"ii"! ,a%( )e)ii$i


7/26

ti&e HLA H!)a% Le!/*/,t A%ti(e% te'te%t! Resi$* )e%i%($at

20 B &a"a i%"ii"! ,a%( )e)ii$i ti&e HLA DR< ata! DR4

b ;a$t*' I)!%**(i

Res&*% ab%*')a "i)a%a a%ti b*"i te'a'a# &a"a -a'i%(a% %*')a

t!b!# "e%(a% /a'a be'ea$si -a'i%(a% te'seb!t seba(ai -a'i%(a%

asi%(

/ ;a$t*' i%($!%(a%

>i'!s @ t*$si% te'te%t! "a&at )e)a/! &'*ses ,a%( "a&at

)e%i)b!$a% "est'!$si se beta

2 DM ti&eII @ NIDDM

Me$a%is)e ,a%( te&at )e%,ebab$a% 'esiste%si i%s!i% "a% se$'esi

i%s!i% &a"a DM ti&e 11 )asi% be!) "i$eta#!i ;a$t*' 'esi$* ,a%(

be'#!b!%(a% a"aa# *besitas+ 'ia,at $e!a'(a+ !sia 'esiste%si i%s!i%

/e%"e'!%( )e%i%($at &a"a !sia C 6= ta#!% 3'!%%e' "a% S!""a't#+

2000

D& Pat(*isi(l(gi

Diabetes Meit!s )e%(aa)i "e.isie%si i%s!i% )e%,ebab$a% (!$a(*%

)e%i%($at se#i%((a te'-a"i &e)e/a#a% (!a ba'! :!$*%e*(e%esis ,a%(

)e%,ebab$a% )etab*is)e e)a$ )e%i%($at $e)!"ia% te'-a"i &'*ses

&e)be%t!$a% $et*% $et*(e%esis Te'-a"i%,a &e%i%($ata% $et*% "i"aa) &as)a a$a% )e%,ebab$a% $et*%!'ia $et*% "i"aa) !'i%e "a% $a"a'

%at'i!) )e%!'!% se'ta PH se'!) )e%!'!% ,a%( )e%,ebab$a% asi"*sis

Di.isie%si i%s!i% )e%,ebab$a% &e%((!%aa% (!$*sa *e# se )e%-a"i

)e%!'!% se#i%((a $a"a' (!$*sa "a'a# "aa) &as)a ti%((i

#i&e'(i$e)ia

Ji$a #i&e'(i$e)ia%,a &a'a# "a% )eebi#i a)ba%( (i%-a )a$a ti)b!

(i$*s!'ia :!$*s!'ia i%i a$a% )e%,ebab$a% "e!'esis *s)*ti$ ,a%(


8/26

)e%i%($at$a% &e%(e!a'a% $e)i# &*i!'i "a% ti)b! 'asa #a!s &*i"i&si

se#i%((a te'-a"i "e#i"'asi :!$*s!'ia )e%,ebab$a% $esei)ba%(a% $a*'i

%e(ati. se#i%((a )e%i)b!$a% 'asa a&a' &*i.a(.iPe%((!%aa% (!$*sa

*e# se )e%!'!% )e%(a$ibat$a% &'*"!$si )etab*is)e e%e'(i )e%-a"i

)e%!'!% se#i%((a t!b!# )e%-a"i e)a#

Hi&e'(i$e)ia "a&at )e)&e%(a'!#i &e)b!!# "a'a# $e/i a'te'i $e/i

se#i%((a s!&ai )a$a%a% "a% *$si(e% $e &e'i.e' )e%-a"i be'$!'a%( ,a%(

a$a% )e%,ebab$a% !$a ti"a$ se)b!#5se)b!# Ka'e%a s!&ai )a$a%a%

"a% *$si(e% ti"a$ a"e$!at ,a%( )e%(a$ibat$a% te'-a"i%,a i%.e$si "a%

te'-a"i (a%(('e% ata! !$!s

:a%((!a% &e)b!!# "a'a# )e%,ebab$a% ai'a% $e 'eti%a )e%!'!%

se#i%((a s!&ai )a$a%a% "a% *$si(e% be'$!'a%(+ a$ibat%,a &a%"a%(a%

)e%-a"i $ab!' Saa# sat! a$ibat !ta)a "a'i &e'!ba#a% )i$'*as$!e'

a"aa# &e'!ba#a% &a"a st'!$t!' "a% .!%(si (i%-a se#i%((a te'-a"i

%e.'*&ati Diabetes )e)&e%(a'!#i sa'a. sa'a. &e'i.e'+ siste) sa'a.

*t*%*) "a% siste) sa'a. &!sat se#i%((a )e%(a$ibat$a% %e!'*&ati P'i/e+

2000

E& %ani*estasi Klinik

Me%!'!t Ma%s-*e'+ 2001 Diabetes Meit!s aa%,a "i&e'$i'a$a% "e%(a%

a"a%,a (e-aa ,ait!

1 P*i!'i se'i%( $e%/i%( "aa) -!)a# ba%,a$

2 P*i"i&si ba%,a$ )i%!)


9/26


10/26

1 Pe%,a$it :i%-a

Saa# sat! a$ibat !ta)a "a'i &e'!ba#a%5&e'!ba#a%

)i$'*as$!e' a"aa# &e'!ba#a% &a"a st'!$t!'a "a% .!%(si

(i%-a3ia $a"a' (!$*sa "aa) "a'a# )e%i%($at+ )a$a

)e$a%is)e .it'asi (i%-a a$a% )e%(aa)i st'ess ,a%(

)e%,ebab$a% $eb*/*'a% &'*tei% "a'a# "aa) !'i%e

S)et8e'+2000

2 Pe%,a$it Mata

Pe%"e'ita DM a$a% )e%(aa)i (e-aa &e%(ei#ata% sa)&ai

$eb!taa% $e!#a% &e%(ei#ata% $ab!' ti"a$ sea! "isebab$a%

%e!'*&ati Kata'a$ "isebab$a% $a'e%a #i&e'(i$e)ia ,a%(

be'$e&a%-a%(a% )e%,ebab$a% &e)be%($a$a% e%sa "a%

$e'!sa$a% e%sa *%(+16


11/26

se5se $!$! $a$i ,a%( )e%eba "a% $a!s "e)i$ia% -!(a &a"a

"ae'a# "ae'a# ,a%( te'$e%a t'a!)a


12/26

"e%(a% &e%((!%aa% *bat5*bata% a%ti DM "e%(a% "*sis

)a$si)a ata! )e%(aa)i $*%t'a i%"i$asi "e%(a% *bat5*bata%

te'seb!t 3ia )e%(aa)i $et*asi"*sis+ #i&e'*s)*a' asi"*sis

a$tat+ st'ess be'at $a'e%a i%.e$si siste)i$+ &asie% *&e'asi

be'at + a%ita #a)i "e%(a% (e-aa DM ,a%( ti"a$ "a&at

"i$*%t'* "e%(a% &e%(e%"aia% "iet

2 Je%is i%s!i%

a I%s!i% $e'-a /e&at -e%is%,a a"aa# 'e(!e' i%s!i%+ /'istai%

8i%$+ "a% se)ie%te

b I%s!i% $e'-a se"a%( Je%is%,a a"aa# NPH Net'a

P'*ta)i%e Ha(e'"*%

/ I%s!i% $e'-a a)bat Je%is%,a a"aa# PFI P'*ta)i%e Fi%/

I%s!i%

2 Pe%ataa$sa%aa% Se/a'a Ke&e'aata%

a Diet

Saa# sat! &ia' !ta)a &e%(e*aa% DM a"aa# &e'e%/a%aa%

)a$a%a% aa!&!% tea# )e%"a&at &e%,!!#a% &e'e%/a%aa%

)a$a%a%+ ebi# "a'i =0G &asie% ti"a$ )ea$sa%a$a%%,a Pe%"e'ita

DM sebai$%,a )e)&e'ta#a%$a% )e%! ,a%( sei)ba%( "e%(a%

$*)&*sisi I"ea%,a se$i(ta' 6?G $a'b*#i"'at+ 20G e)a$ "a% 12G

&'*tei% Ka'e%a it! "iet ,a%( te&at !%t!$ )e%(e%"ai$a% "a%

)e%/!(a# a(a' be'at ba"a% i"ea "e%(a% /a'a

1 K!'a%(i Ka*'i

2 K!'a%(i Le)a$


13/26

st'ess 3a(i &asie% DM )ea$!$a% *a#'a(a "e%(a% te'at!' a$a%

ebi# bai$ teta&i -a%(a%))ea$!$a% *a#'a(a te'a! be'at

& Pemeriksaan Penn.ang

Ma%s-*e'+ 1 )e%(ata$a% ba#a &e)e'i$saa% &e%!%-a%( sa%(at &e%ti%(

"ia$!$a% &a"a &e%"e'ita DM !%t!$ )e%e(a$$a% "ia(%*se $e*)&*$

'esi$* DM ,ait! $e*)&*$ !sia "easa t!a ebi# "a'i 40 ta#!%+ *besitas+

#i&e'te%si+ 'ia,at $e!a'(a DM 'ia,at $e#a)ia% "e%(a% ba,i ebi# "a'i

4000 ('a)+ 'ia,at DM sea)a $e#a)ia% Pe)e'i$saa% "ia$!$a% "e%(a%

&e)e'i$saa% (!a "a'a# sea$t! $e)!"ia% "a&at "ii$!ti "e%(a% Test

T*e'a%si :!$*sa O'a TT:O U%t!$ $e*)&*$ 'esi$* ,a%( #asi

&e)e'i$saa% %,a %e(ati.+ &e'! &e)e'i$saa% !a%( setia& ta#!%%,a

Pa"a &e)e'i$saa% "e%(a% DM "i&e)e'i$saa% a$a% "i"a&at$a% #asi (!a

"a'a# &!asa C140 )(@" &a"a "!a $ai &e)e'i$saa% Da% (!a "a'a# &*st

&'a%"ia C200)(@" Seai% it! -!(a "a&at -!(a "ia$!$a% &e)e'i$saa%

a%ta'a ai%

1 Aset*% &as)a $et*% C &*siti. se/a'a )e%/**$

2 Asa) e)a$ bebas$a"a' i&i" "a% $*este'* )e%i%($at


14/26

Daa) i"e%titas "ata@ &et!%-!$ ,a%( "a&at $ita &'e"i$si$a% a"aa#

U)!'+ $a'e%a sese*'a%( )e)ii$i 'esi$* ti%((i !%t!$ te'$e%a "iabetes

)eit!s ti&e II &a"a !)!' "iatas 40 ta#!%

2 Ke!#a% Uta)a

Pasie% "iabetes )eit!s "ata%( $e'!)a# sa$it "e%(a% $e!#a% !ta)a

,a%( be'be"a5be"a Pa"a !)!)%,a sese*'a%( "ata%( $e'!)a# sa$it

"e%(a% (e-aa $#as be'!&a &*i.a(ia+ &*i!'ia+ &*i"i&sia+ e)as+ "a%

be'at ba"a% t!'!%


15/26

)etab*is)e ,a%( "a&at )e)&e%(a'!#i stat!s $ese#ata%

&e%"e'ita

b P*a Ei)i%asi

A"a%,a #i&e'(i$e)ia )e%,ebab$a% te'-a"i%,a "i!'esis *s)*ti$

,a%( )e%,ebab$a% &asie% se'i%( $e%/i%( &*i!'i "a%

&e%(e!a'a% (!$*sa &a"a !'i%e (!$*s!'ia Pa"a ei)i%asi ai

'eati. ti"a$ a"a (a%((!a%

/ P*a Isti'a#at "a% Ti"!'

A"a%,a &*i!'i+ "a% sit!asi '!)a# sa$it ,a%( 'a)ai a$a%

)e)&e%(a'!#i a$t! ti"!' "a% isti'a#at &e%"e'ita+ se#i%((a &*a

ti"!' "a% a$t! ti"!' &e%"e'ita

" P*a A$tiitas

A"a%,a $ee)a#a% *t*t *t*t &a"a e$ste')itas )e%,ebab$a%

&e%"e'ita ti"a$ )a)&! )ea$sa%a$a% a$tiitas se#a'i5#a'i se/a'a

)a$si)a+ &e%"e'ita )!"a# )e%(aa)i $eea#a%

e P*a &e'se&si "a% $*%se& "i'i

A"a%,a &e'!ba#a% .!%(si "a% st'!$t!' t!b!# a$a% )e%,ebab$a%

&e%"e'ita )e%(aa)i (a%((!a% &a"a (a)ba'a% "i'i a)a%,a

&e'aata%+ ba%,a$%,a bia,a &e'aata% "a% &e%(*bata%

)e%,ebab$a% &asie% )e%(aa)i $e/e)asa% "a% (a%((!a% &e'a%

&a"a $e!a'(a se. estee)

. P*a se%s*'i "a% $*(%iti.

Pasie% "e%(a% "iabetes )eit!s /e%"e'!%( )e%(aa)i %e!'*&ati @

)ati 'asa &a"a $a$i se#i%((a ti"a$ &e$a te'#a"a& a"a%,a t'a!)a

( P*a se$s!a "a% 'e&'*"!$siA%(i*&ati "a&at te'-a"i &a"a siste) &e)b!!# "a'a# "i *'(a%

'e&'*"!$si se#i%((a )e%,ebab$a% (a%((!a% &*te%si se$s+

(a%((!a% $!aitas )a!&!% e'e$si+ se'ta )e)be'i "a)&a$ &a"a

&'*ses e-a$!asi se'ta *'(as)e

# P*a )e$a%is)e st'es "a% $*&i%(

La)a%,a a$t! &e'aata%+ &e'-aa%a% &e%,a$it ,a%( $'*%i$+

&e'asaa% ti"a$ be'"a,a $a'e%a $ete'(a%t!%(a% )e%,ebab$a% 'ea$si


16/26

&si$**(is ,a%( %e(ati. be'!&a )a'a#+ $e/e)asa%+ )!"a#

te'si%((!%( "a% ai% ai%+ "a&at )e%,ebab$a% &e%"e'ita ti"a$

)a)&! )e%((!%a$a% )e$a%is)e $*&i%( ,a%( $*%st'!$ti. @

a"a&ti.

= Pe%($a-ia% ;isi$

a Kea"aa% U)!)

Mei&!ti $ea"aa% &e%"e'ita+ $esa"a'a%+ s!a'a bi/a'a+ ti%((i ba"a%+

be'at ba"a% "a% ta%"a ta%"a ita

b Hea" t* T*e

1 Ke&aa Le#e'

Ka-i be%t!$ $e&aa+ $ea"aa% 'a)b!t+ a"a$a# &e)besa'a%

&a"a e#e'+ tei%(a $a"a%(5$a"a%( be'"e%(i%(+ a"a$a#

(a%((!a% &e%"e%(a'a%+ i"a# se'i%( te'asa teba+ !"a#

)e%-a"i ebi# $e%ta+ (i(i )!"a# (*,a#+ (!si )!"a#

be%($a$ "a% be'"a'a#+ a&a$a# &e%(i#ata% $ab!' @ (a%"a+

"i&*&ia+ e%sa )ata $e'!#

2 Siste) i%te(!)e%

Ka-i T!'(*' $!it )e%!'!% &a"a &asie% ,a%( se"a%(

)e%(aa)i "e#i"'asi+ $a-i &!a a"a%,a !$a ata! a'%a

$e#ita)a% be$as !$a+ $ee)baba% "a% s!#! $!it "i "ae'a#

se$ita' !$!s "a% (a%('e%+ $e)e'a#a% &a"a $!it se$ita'

!$a+ te$st!' 'a)b!t "a% $!$!


17/26

P*i!'i+ 'ete%si* !'i%e+ i%$*%ti%e%sia !'i%e+ 'asa &a%as ata!

sa$it saat be'$e)i#Keebi#a% (!$*sa a$a% "ib!a%( "aa)

be%t!$ !'i%

6 Siste) )!s$!*s$eeta

A"a%,a $atab*is)e e)a$+ Pe%,eba'a% e)a$ "a%+

&e%,eba'a% )asa *t*t+be'!ba# Pasie% -!(a /e&at ea#+

e)a#

7 Siste) %e!'**(is

3e'#!b!%(a% "e%(a% $*)&i$asi $'*%is ,ait! &a"a s,ste)

%e!'**(is &asie% se'i%( )e%(aa)i &e%!'!%a% se%s*'is+

&a'ast#esia+ a%astesia+ eta'(i+ )e%(a%t!$+ 'e.e$ a)bat+

$a/a! )e%ta+ "is*'ie%tasi

6 Pe)e'i$saa% Dia(%*sti$

a Tes t*e'a%si :!$*sa TT: )e)a%-a%( ebi# besa' "a'i

200)(@" 3iasa%,a+ tes i%i "ia%-!'$a% !%t!$ &asie% ,a%(

)e%!%-!$$a% $a"a' (!$*sa )e%i%($at "ibaa# $*%"isi st'ess

b :!a "a'a# &!asa %*')a ata! "iatas %*')a

/ Essei #e)*(*bi% (i$*isat "iatas 'e%ta%( %*')a

" U'i%aisis &*siti. te'#a"a& (!$*sa "a% $et*%

e K*este'* "a% $a"a' t'i(ise'i"a se'!) "a&at )e%i%($at

)e%a%"a$a% $eti"a$a"e$!ata% $*%t'* (i$e)i$ "a% &e%i%($ata%

&'*&e%sitas &a"a te'-a"i%,a ate'*s$e'*sis

$& Diagn(sa keperawatan

1 Risi$* $eti"a$stabia% $a"a' (!$*sa "a'a#

2 Keti"a$sei)ba%(a% %!t'isi $!'a%( "a'i $eb!t!#a% t!b!#


18/26

NO& DIA#NOSA T!0!AN INTERVENSI

1 Risik(

Keti)akstailan

Ka)ar

#lk(saDarah

Setea# "ibe'i$a% as!#a%

$e&e'aata% sea)a B 24 -a) "i#a'&a$a%

NOC Label :

1& $l(() #l3(se Le/el

5 :!a"a'a#5 :!a !'i%e5 Ket*% !'i%e$et

s$aa 1 &e%,i)&a%(a% &a'a#

s$aa2 &e%,i)&a%(a%s!bsta%sia

s$aa < &e%,i)&a%(a%se"a%(

s$aa 4 &e%,i)&a%(a%'i%(a%

s$aa = ti"a$ a"a &e%,i)&a%(a%

2& 4pergl43emia Se/erit4

5 Pe%i%($ata%&e%(e!a' a% !'i%e

5 Pe%i%($ata% 'asa #a!s5 Kea&a'a% ,a%(

be'ebi#5 Maaise5 Rasa ti"a$e%a$ 5 Ke$ab!'a%&e%(ei#ata

%5 Ke#ia%(a%be'atba"a%

ta%&a aas a%5 Ke#ia%(a%%a.s!)a$a

%5 M!a5 M!$*sabibi'$e'i%(5 K*%se%t'asibe'/aba%(

5 Pe'!ba#a% stat!s)e%ta5 Ka"a'

(!$*sa"a'a#ti%((iKet

s$aa 1 &e%,i)&a%(a% &a'a#

s$aa 2 &e%,i)&a%(a%s!bsta%sia

s$aa < &e%,i)&a%(a%

se"a%(

s$aa 4 &e%,i)&a%(a%

NIC Label :

1& 4pergl43emia %anagement

5 Pa%ta!$a"a'(!a"a'a#

5 Pa%ta!ta%"a"a%(e-aa"a'i#i&e'(i$e)ia &*,!'ia+ &*,"i&sia+ &*,a(ia+$ee)a#a%+ eta'(i+ )aaise+$e$ab!'a%&e%(i#ata%+

ata!sa$it$e&aa5 Pa%ta!$et*%"aa) !'i%e5 Pa%ta!te$a%a%"a'a#*'t*stati$

"a%%a"i5 Ke*a i%s!i%

se&e'ti$ete%t!a%

5 Pasti$a% i%ta$e /ai'a% *'a5 Pa%ta! stat!s /ai'a% i%&!t

"a% *!t&!t5 Pe'ta#a%$a%a$ses I>5 I"e%ti.i$asi&e%,ebab&asti#i&

e'(i$e)ia

5 A%tisi&asi$*%"isi$eti$a$eb!t!#a% i%s!i% be'ta)ba#

5 K!'a%(iati#a%$eti$a$a"a'(!a"a'a#)eebi#i 2=0)(@"Lata!te'"a&at$et*%"aa) !'i%e

5 I%st'!$si$a%&asie%)e%(e%ai&e%/e(a#a%"a%)a%a-e)e%!%t!$#i&e'(i$e)ia

5 Pe'ta#a%$a%&e)a%ta!a%$a"a' (!a"a'a#se/a'a)a%"i'i

5 A-a'$a%&asie%!%t!$)e%a.si'

$a%$a"a'(!$*sa"a'a#%,a5 Uas/atata%(!a"a'a#be'sa)a

&asie%"a%$e!a'(a5 I%st'!$si$a%!%t!$)ea$!$a%

test $et*%"aa) !'i%e5 A%-!'$a% &asie% "a% $e!a'(a

te%ta%( )a%a-e)e% "iabetessea)a sa$it+ te')as!$ &e%((!%aa% i%s!i% "a% @ ata!a(e% *'a+ &e)a%ta!a%as!&a% /ai'a%+ &e%((a%tia%$a'b*#i"'at+ "a% $a&a% #a'!s

)e%/a'i ba%t!a% &'*.esi*%a$ese#ata%+ ,a%( ses!ai

5 ;asiitasi$etaata% "iet"a%ati#a%

5 La$!$a%tes$a"a'(!$*sa&a"aa%((*ta$e!a'(a

2& Ntriti(nal %(nit(ring

5 Pa%ta!be'atba"a%&asie%5 Pa%ta!&e't!)b!#a%"a%&e'$e

)ba%(a%


19/26

'i%(a%


5

2 Keti)akseimangan

Ntrisi Krang )ari

Kethan Th

Setea# "ibe'i$a% as!#a%$e&e'aata% sea)a B 24 -a) "i#a'&a$a%

NOC Label :

1& Ntriti(nal stats

5 I%ta$e %!t'ie%t

5 I%ta$e )a$a%a%5 I%ta$e /ai'a%5 Te%a(a5 Rasi*be'atba"a%"a%ti

%((iba"a%5 Hi"'asi

Ket

s$aa 1 &e%,i)&a%(a% &a'a#

s$aa 2 &e%,i)&a%(a%s!bsta%sia

s$aa < &e%,i)&a%(a%se"a%(

s$aa 4 &e%,i)&a%(a%'i%(a%


2& Ntriti(nal Stats :

Ntrient Intake5 I%ta$e $a*'i5 I%ta$e &'*tei%

5 I%ta$e $a'b*#i"'at5 I%ta$e ita)i%5 I%ta$e )i%e'a

$et

s$aa 1 ti"a$a"e$!at

s$aa 2 se"i$ita"e$!at

s$aa < /!$!&

s$aa 4 &e%,i)&a%(a%

NIC Label :

1& Ntriti(nal %(nit(ring

5 Pa%ta! be'at ba"a% &asie%5 Pa%ta! &e't!)b!#a% "a%

&e'$e)ba%(a%

5 Pa%ta! t!'(*' $!it5 I"e%ti.i$asi ab%*')aitas

$!it &e'"a'a#a%+ te'a! ba%,a$ )e)a'+ &e%,e)b!#a%!$a ,a%( b!'!$

5 I"e%ti.i$asi ab%*')aitas

'a)b!t $e'i%(+ 'a&!#+'*%t*$

5 I"e%ti.i$asi ab%*')aitas$!$! be%t!$ se%"*$+ 'a&!#+ be'&!%/a$ '!%/i%(

5 Pa%ta! )!a "a% )!%ta#

5 Pa%ta! i%ta$e "a% "iet $a*'i5 Te%t!$a% 'e$*)e%"asi

s!)be' e%e'(, "iet ,a%("i&e'b*e#$a%+ te'(a%t!%($*%"isi &asie% !sia+ be'at ba"a%+ -e%is $ea)i%+

a$tiitas .isi$5 I"e%ti.i$asi &e'!ba#a%

a$tiitas a$ibat $eea#a%5 Pa%ta! ti&e "a% -!)a#

ati#a% biasa5 Pa%ta! stat!s )e%ta

bi%(!%(+ "e&'esi+ /e)as5 M!ai&e%(*bata%ata!'!-!$a%+

bia"i&e'!$a%2& Ntriti(n %anagement

5 Te%t!$a% stat!s %!t'isi&asie%5 I"e%ti.i$asiae'(i)a$a%a%ata

!i%t*e'a%si5 3e'ita#!&asie%te%ta%($eb!t!

#a%%!t'isi "is$!si&a%"!a%"iet "a%&i'a)i"a)a$a%a%

5 Te%t!$a%ba%,a$%,a$a*'i"a%ti&e%!t'isi ,a%( "i&e'!$a%

5 Ses!ai$a% "iet

e"ia$a%)a$a%a%ti%((i &'*tei%+


20/26

'i%(a%

s$aa = a"e$!at

)e%(!'a%(iata!)e%a)ba#$a*'i+)e%(!'a%(iata!)e%a)ba#

ita)i%+ )i%e'a+"a%s!&e)e%

5 Raat$ebe'si#a%)!!t&asie%sebe!))a$a%

5 Ke*a&e%(*bata%@)e"i$asis

ebe!))a$a%5 Pa%ta! i%ta$e "a% "iet $a*'i5 Pa%ta!(e-aa$eebi#a%ata!$e

$!'a%(a%be'atba"a%5 I%st'!$si$a%&asie%!%t!$)e)

a%ta! i%ta$e "a% "iet $a*'i

5 Kelebihanvolume cairan

NOC : Fluid Balance

- Terbebas dariedema, efusi,

anasarka- Bunyi nafas

bersih,tidak adanyadipsnea

- Memilihara tekananvena sentral,tekanan kapilerparu, output jantungdan vital signnormal.

NI, :

Fluid Manageen! :

Kaji status cairan ; timbang

beratbadan,keseimbanganmasukan dan haluaran,turgor kulit dan adanyaedema

Batasi masukan cairanIdentikasi sumber potensial

cairan !elaskan pada pasien dan

keluarga rasionalpembatasan cairan

Kolaborasi pemberian cairansesuai terapi.

He"dial#$i$ !%e&a'#

". #mbil sampel darah danmeninjau kimia darah$misalnya B%&, kreatinin,natrium, pottasium,tingkat phospor' sebelumpera(atan untukmengevaluasi responthdp terapi.

). *ekam tanda vital+ beratbadan, denyut nadi,pernapasan, dan tekanandarah untukmengevaluasi responterhadap terapi.

. -esuaikan tekanan ltrasiuntuk menghilangkan jumlah yang tepat daricairan berlebih di tubuhklien.Bekerja secara kolaboratif

dengan pasien untuk

menyesuaikan panjang


21/26

dialisis, peraturan diet,

keterbatasan cairan dan

obatobatan untuk

mengatur cairan dan

elektrolit pergeseranantara pengobatan

6 #anggan Rasa

N4aman 7N4eri

Akt 8

NO, :

a Pain le/el

Pain 3(ntr(l

3 ,(m*(rt le/el

Setea# "ia$!$a% ti%"a$a%$e&e'aata% sea)a B 24

-a) Pasie% ti"a$ )e%(aa)i%,e'i+ "e%(a%

Kriteria asil

a Ma)&! )e%(*%t'* %,e'ita#! &e%,ebab %,e'+)a)&! )e%((!%a$a%te$%i$ %*%.a')a$**(i!%t!$ )e%(!'a%(i %,e'i+

)e%/a'i ba%t!a% b Mea&*'$a% ba#a %,e'i

be'$!'a%( "%e(a%

)e%((!%a$a%)a%a-e)e% %,e'i

/ Ma)&! )e%(e%ai %,e'i

s$aa+ i%te%sitas+.'e$!e%si "a% ta%"a%,e'i

" Me%,ata$a% 'asa %,a)a%setea# %,e'i be'$!'a%(

e Ta%"a ita "aa)

'e%ta%( %*')a. Ti"a$ )e%(aa)i

(a%((!a% ti"!'

NI, :

a La$!$a% &e%($a-ia% %,e'ise/a'a $*)&'e#e%si. te')as!$ *$asi+ $a'a$te'isti$+ .!'asi+.'e$!e%si+ $!aitas "a% .a$t*' &'esi&itasi

b Obse'asi 'ea$si %*%e'ba "a'i$eti"a$%,a)a%a%

/ 3a%t! &asie% "a% $e!a'(a

!%t!$ )'%/a'i "a% )e%e)!$a%"!$!%(a%" K*%t'* i%($!%(a% ,a%( "a&at

)e)&e%(a'!#i %,e'i se&e'tis!#! '!%(a%+ &e%/a#a,aa% "a%$ebisi%(a%

e K!'a%(i .a$t*' &'esi&itasi %,e'i. Ka-i ti&e "a% s!)be' %,e'i

!%t!$ )e%e%t!$a% i%te'e%si( A-a'$a% te%ta%( te$%i$ %*%

.a')a$**(i %a&as "aa)+'ea$sasi+ "ist'a$si+ $*)&'es#a%(at@"i%(i%

# 3e'i$a% i%.*')asi te%ta%( %,e'ise&e'ti &e%,ebab %,e'i+ be'a&aa)a %,e'i a$a% be'$!'a%( "a%a%tisi&asi $eti"a$%,a)a%a% "a'i &'*se"!'

i M*%it*' ita si(% sebe!) "a%ses!"a# &e)be'ia% a%a(esi$

9 #nsietas NOC

#n/iety selfcontrol

#n/iety level

0oping

-etelah melakukan

asuhan kepera(atan

/)1 jam diharapkan

rasa cemas pasien

berkurang dengan

NIC

#n/iety *eduction

$penurunan kecemasan'

a. 2unakan pendekatanyang menenangkan

b. !elaskan semua prosedurdan apa yang dirasakanselama prosedur

c. 3ahami prespektif pasienterhadap situasi stress

d. Temani pasien untuk


22/26


23/26

te'-a"i &a"a ta#a& ea!asi &'*ses "a% ea!asi #asi Ea!asi be'.*$!s

&a"a $ete&ata% &e'aata% ,a%( "ibe'i$a% "a% $e)a-!a% &asie% ata!

$e)!%"!'a% &asie% te'#a"a& #asi ,a%( "i#a'a&$a% Ea!asi )e'!&a$a%

&'*ses ,a%( i%te'a$ti. "a% $*%ti%! $a'e%a setia& ti%"a$a% $e&e'aata%

"ia$!$a%+ 'es&*% $ie% "i/atat "a% "iea!asi "aa) #!b!%(a%%,a "e%(a%

#asi ,a%( ,a%( "i#a'a&$a% Ke)!"ia% be'"asa'$a% 'es&*% $ie%+ "i'eisi

i%te'e%si $e&e'aata% ata! #asi ,a%( "i&e'!$a% A"a 2 $*)&*%e% !%t!$

)e%(ea!asi $!aitas ti%"a$a% /*)&!te' $e&e'aata%+ ,ait!

1 P'*ses s!)ati.

;*$!s ti*&ei%i a"aa# a$tiitas "a'i &'*ses $e&e'aata% "a% #asi

$!aitas &ea,a%a% ti%"a$a% $e&e'aata% Ea!asi &'*ses #a'!s

"ia$sa%a$a% ses!"a# &e'e%/a%aa% $e&e'aata%+ "ia$sa%a$a%

!%t!$ )e)ba%t! $ee.e$ti.a% te'#a"a& ti%"a$a%

2 Hasi .*')ati.

;*$!s ea!asi #asi a"aa# &e'!ba#a% &e'ia$! ata! stat!s

$ese#ata% $ie% &a"a a$#i' ti%"a$a% $e&e'aata% $ie%


24/26

DA+TAR P!STAKA

3'!%%e' S!""a't# + 2000 Buku Ajar Keperawatan Medikal – Bedah

Te'-e)a#a% S!8a%%e 9 S)et8e' E"isi ? >* ? Pe%e'bit 3!$!

Ke"*$te'a% E:9 Ja$a'ta

3!e/#e/$+ :*'ia M+ 3!t/#e'+ H*a'" K+ D*/#te')a%+ J*a%%e M+ Wa(%e'+

S#e', M 201


25/26

3a#asa Pete' Ja$a'ta E:9

S)et8e' 9 S!8a%%e+ 3'!%%e' S!""a't# 2002 Buku Ajar Keperawatan

Medikal Bedah E:9 Ja$a'ta

Wi-a,a P!t'i 201


26/26

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