Pengkajian DM PIH

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JURUSAN KEPERAWATAN

FAKULTAS KEDOKTERAN

UNIVERSITAS BRAWIJAYA

PENGKAJIAN DASAR KEPERAWATAN

Nama Mahasiswa : DINA MUKMILAH M Tempat Praktik : RSSA

NIM : 1150702011102! T"#$ Praktik : 2% &kt'(er 201!

A. Identitas Klien

Nama :N)$ *askia$$$$$$$$$$$$$$$$$$$$$$$$N'$ RM : ti+ak terka,i

Usia :2 tah-. T"#$ Mas-k :27 &kt'(er 201!

/e.is ke#ami. :Peremp-a. $$$$$$$$$$$$$$$$$$$$$T"#$ Pe."ka,ia. :2% &kt'(er 201!

A#amat :Saw' ,a,ar $$$$$$$$$$$$$$$$$$$$$$$S-m(er i.'rmasi :pasie. +a. s-ami

N'$ te#ep'. : ti+ak terka,i Nama k#"$ +ekat )" (isa +ih-(-."i:

T.$ iki)

Stat-s per.ikaha. :Me.ikah $$$$$$$$$$$$$$$$$$$$$$$$$$$$

A"ama :Is#am Stat-s :S-ami pasie.

S-k- :/awa A#amat : Saw' ,a,ar

Pe.+i+ika. :SMP N'$ te#ep'. : ti+ak terka,i

Peker,aa. :I(- R-mah Ta.""a Pe.+i+ika. :SMA

Lama (erker,a : Peker,aa. :S-pir per-sahaa.

B. Status kesehatan Saat Ini

1$ Ke#-ha. -tama : p-si." +a. #emas

2$ Lama ke#-ha. : se,ak 2 hari )a." #a#-

$ K-a#itas ke#-ha. : p-si." seperti (erp-tarpitar3 ska#a 4

!$ akt'r pe.6et-s : ti(ati(a p-si." saat istirahat +a. ti+ak (erk-ra." wa#a- s-+ah

ti+-ra.

5$ akt'r pem(erat : Riwa)at DM 2 tah-. #a#-3 kehami#a.$ Upa)a )"$ te#ah +i#ak-ka. : istirahat +a. +i(awa ke RS kare.a ti+ak k-.,-." re+a

7$ Dia".'sa me+is :

a$ Riwa)at DM tipe 2 Ta.""a# 2 tah-. )a." #a#-

($ DM Tipe 2 p's "a."re. Ta.""a# 27 &kt'(er 201!

6$ Preek#amsia Ta.""a# 27 &kt'(er 201!

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Riwayat Kesehatan Saat Ini

K#ie. hari )a." #a#- ,emp'# kaki ka.a. pasie. terke.a keriki# +a. #-ka tapi ti+ak sem(-h

sem(-h$ Se,ak 2 hari #a#- k#ie. merasa p-si." +a. #emas3 +ipakai istirahat tapi ti+ak mem(aik3

k#ie. tak-t kem-+ia. +i(awa ke U8D ta.""a# 27 &kt 201! p-k-# 1%$00 9I$ Pe."ka,ia. +iper'#eh

TD 10;100mmH" +a. k#ie. se+a." hami# % (-#a.$ K#ie. kem-+ia. +i+ia".'sa me."a#ami pre

ek#amsia kare.a +item-ka pr'tei.-ria se#ama

5 me.it$ Kem-+ia. +itam(ahka. M"S&!!0> 5 "r IM +e."a. 1 mL #i".'6ai.e$ Ta.""a# 27 &kt

201! p-k-# 21$00 k#ie. +ipi.+ahka. ke r-a." perawata.$

Riwayat Kesehatan Terdahulu

%$ Pe.)akit )" per.ah +ia#ami:

a$ Ke6e#akaa. ?,e.is @ wakt- :

($ &perasi ?,e.is @ wakt- :

6$ Pe.)akit:

Kr'.is :DM tipe II se,ak tah-. 2012$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

Ak-t :$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

+$ Terakhir mas-ki RS : Tah-. 2012

4$ A#er"i ?'(at3 maka.a.3 p#ester3 +##:

Tipe Reaksi Ti.+aka.

$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

10$ Im-.isasi:? B8 ? Hepatitis

? P'#i' ? Bampak

? DPT ?C Lenka!

11$ Ke(iasaa.:

/e.is rek-e.si /-m#ah Lama.)a

Mer'k'k

K'pi 1 sehari 200 66 se,ak 15 tah-. #a#-

A#k'h'#

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12$ &(at'(ata. )" +i"-.aka.:

/e.is Lama.)a D'sis

8#i(e.k#ami+ ?2 tah-. #a#- 1 (-#a. ti+ak terka,i

". Riwayat Keluara

apak +a. i(- k#ie. s-+ah me.i.""a# kare.a pe.)akit DM tipe II

8EN&8RAM

D. Riwayat Linkunan

/e.is R-mah Peker,aa.

Ke(ersiha. ersih$$$$$$$$$$$$$$$$$$$$$$$$$$$ ti+ak terka,i

aha)a ke6e#akaa. ti+ak a+a ti+ak terka,i

P'#-si ti+ak a+a $ ti+ak terka,i

e.ti#as 6-k-p3 a+a ,e.+e#a +a. (isa +i(-ka ti+ak terka,i

Pe.6aha)aa. mema+ai $ ti+ak terka,i

E. P#la Akti$itas%Latihan

R-mah R-mah Sakit

Maka.;mi.-m 0$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ 2

Ma.+i 0 2

erpakaia.;(er+a.+a. 0 2

T'i#eti." 0 2

M'(i#itas +i tempat ti+-r 0 2

erpi.+ah 0 2

er,a#a. 0 2

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Naik ta.""a 0 2

Pemberian Skor: 0 = mandiri, 1 = alat bantu, 2 = dibantu orang lain partial, 3 = dibantu

orang lain total, 4 = tidak mampu

&. P#la Nutrisi 'eta(#likR-mah R-mah Sakit

/e.is +iit;maka.a. (er=ariasi 1400 ka# re.+ah "aram$$$$$

rek-e.si;p'#a ti+ak te.t- (isa !;hari maka.


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- K'.siste.si 6air 6air $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

- 9ar.a @ (a- k-.i."3 .'rma# k-.i."3 .'rma#$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

- Kes-#ita. $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

- Upa)a me."atasi $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

*. P#la Tidur%Istirahat

R-mah R-mah Sakit

Ti+-r sia.":Lama.)a 0 me.it (e#-m ti+-r sia."

- /am Fs;+F ti+ak terka,i

- Ke.)ama.a. st#h$ ti+-r .)ama.

- Ti+-r ma#am: Lama.)a kirakira ,am

- /am Fs;+F 22$00 G 0!$0

- Ke.)ama.a. st#h$ ti+-r .)ama. k-ra." .)ama.

- Ke(iasaa. s(#m$ ti+-r

- Kes-#ita. a+a kare.a (e#-m (era+aptasi +e."a.

#i."k-."a. (ar- +a. ti+ak (isa miri."

ka.a. +a. kiri kare.a hami#

- Upa)a me."atasi +ie#-se#-s s-ami

I. P#la Ke(ersihan Diri

R-mah R-mah Sakit

Ma.+i:rek-e.si 2;hari 1 +iseka $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

- Pe.""-.aa. sa(-. )a )a $$$$$$$$$$$$$$$$$$

Keramas: rek-e.si ;mi.""- (e#-m keramas$$$$$$$$$$$$$$$$

- Pe.""-.aa. shamp'' )a )a $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

8's'k "i"i: rek-e.si 2;hari 1;hari

- Pe.""-.aa. '+'# )a )a $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

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8a.ti (a,-:rek-e.si 2;hari 1;hari$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

Mem't'." k-k-: rek-e.si 1semi.""- (e#-m mem't'." k-k-

Kes-#ita. se,ak kaki sakit3 kes-#ita. ,a#a. terpasa." kateter $$$$$$$$$$$

$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ Upa)a )" +i#ak-ka. +i(a.t- s-ami +i(a.t- perawat$$$$$$$$$$$

J. P#la T#leransi%K#!in Stres

1$ Pe."am(i#a. kep-t-sa.: ?C se.+iri ? +i(a.t- 'ra." #ai.3 se(-tka.3$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

2$ Masa#ah -tama terkait +e."a. perawata. +i RS ata- pe.)akit ?(ia)a3 perawata. +iri3 +##: ti+ak a+a

$ a." (iasa +i#ak-ka. apa(i#a stress;me."a#ami masa#ah:6erita pa+a s-ami

!$ Harapa. sete#ah me.,a#a.i perawata.:sem(-h3 (isa p-#a."5$ Per-(aha. )a." +irasa sete#ah sakit:ti+ak (isa me#ak-ka. apa )a." +ii."i.ka.

K. P#la Peran + *u(unan

1$ Pera. +a#am ke#-ar"a : istri +a. i(- r-mah ta.""a

2$ Sistem pe.+-k-.":s-ami;istri;a.ak;teta.""a;tema.;sa-+ara;ti+ak a+a;#ai.#ai.3

se(-tka.:s-ami +a. ke#-ar"a

$ Kes-#ita. +a#am ke#-ar"a: ? H-($ +e."a. 'ra." t-a ? H-($+e."a. pasa."a.

? H-($ +e."a. sa.ak sa-+ara? H-($+e."a. a.ak

? Lai.#ai. se(-tka.3: ti+ak terka,i

!$ Masa#ah te.ta." pera.;h-(-."a. +e."a. ke#-ar"a se#ama perawata. +i RS: ti+ak terka,i

5$ Upa)a )" +i#ak-ka. -.t-k me."atasi: ti+ak terka,i

L. P#la K#)unikasi

1$ i6ara: ? C N'rma# ? ahasa -tama:$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

? Ti+ak ,e#as ? ahasa +aerah:$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

? i6ara (erp-tarp-tar ? Re.ta." perhatia.:$$$$$$$$$$$$$$$$$$$$$$$$$$$$

? Mamp- me."erti pem(i6araa. 'ra." #ai.? Aek:$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

2$ Tempat ti.""a#: ?C Se.+iri

? K's;asrama

? ersama 'ra." #ai.3 )ait-:$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

$ Kehi+-pa. ke#-ar"a

a$ A+at istia+at )" +ia.-t: /awa

($ Pa.ta."a. @ a"ama )" +ia.-t: ti+ak terka,i

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6$ Pe."hasi#a. ke#-ar"a: ? Rp$ 250$000 ?C Rp$ 1 ,-ta G 1$5 ,-ta

? Rp$ 250$000 G 500$000 ? Rp$ 1$5 ,-ta G 2 ,-ta

? Rp$ 500$000 G 1 ,-ta ? J 2 ,-ta

'. P#la Seksualitas

1$ Masa#ah +a#am h-(-."a. seks-a# se#ama sakit: ? C ti+ak a+a ? a+a

2$ Upa)a )a." +i#ak-ka. pasa."a.:

? perhatia. ? se.t-ha. ? #ai.#ai.3 seperti3 ti+ak a+a

N. P#la Nilai + Ke!er,ayaan

1$ Apakah T-ha.3 a"ama3 keper6a)aa. pe.ti." -.t-k A.+a3 a

2$ Ke"iata. a"ama;keper6a)aa. )" +i#ak-ka. +ir-mah ?,e.is @ rek-e.si: sh'#at 5 wakt-$ Ke"iata. a"ama;keper6a)aa. ti+ak +apat +i#ak-ka. +i RS: w-+h-

!$ Harapa. k#ie. terha+ap perawat -.t-k me#aksa.aka. i(a+ah.)a: ti+ak a+a

-. Pe)eriksaan &isik

1$ Kea+aa. -m-m :a$ Kesa+ara. : 6'mp's me.tis($ Ta.+ata.+a =ita# : Teka.a. +arah : 1!0;40 mmH" S-h- : 7'B

Na+i : %0;me.it Per.aasa. :14;me.it

6$ Ti.""i (a+a. : 150 6m erat (a+a. : 75 6m2$ Kepa#a +a. Lehera$ Kepa#a : e.t-k : simetris Massa :ti+ak a+a

Distri(-si ram(-t : merata 9ar.a k-#it kepa#a : p-tih s-s-($ Mata : e.t-k : simetris K'.,-."ti=a

P-pi# : ?C reaksi terha+ap 6aha)a ?C is'k'r ? Mi'sis ? Pi. p'i.t ? Mi+riasis Ta.+ata.+a ra+a." : ti+ak a+a -.si pe."#ihata. : ?C aik ? Ka(-r

Pe.""-.aa. a#at (a.t- : ? a ? C Ti+ak Apa(i#a )a me.""-.aka. : ? Ka6a mata ? Le.sa k'.tak

? Mi.-sF$$ka; ki ? P#-sF$ka;ki? si#i.+erFka;ki

Pemeriksaa. mata terakhir : FFFFFFFFFFFFFFFF$$$Riwa)at &perasi :FFFFFFFFFFFFFFFFFFFFF

6$ Hi+-." : e.t-k : simetris 9ar.a : k-.i." #a."sat Pem(e."kaka. : N)eri teka.: Per+araha. : Si.-s : Riw$ A#er"i : Bara me."atasi.)a : Pe.)akit )" per.ah ter,a+i : rek-e.si : Bara me."atasi :

+$ M-#-t +a. Te.""'r'ka. : 9ar.a (i(ir: merah M-k'sa: merah U#k-s : Lesi : Massa : 9ar.a Li+ah : .'rma#3 merah Per+araha. "-si: Karies : Kes-#ita. me.e#a.: 8i"i "e#i"i : Sakit te.""'r'k : 8a.""-a. (i6ara : Pemeriksaa. "i"i terakhir :

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e$ Te#i."a : e.t-k : simetris 9ar.a : k-.i." #a."sat Lesi : Massa : N)eri : s$ Pe.+e."ara.: (aik $A#at (a.t- pe.+e."ara.: Masa#ah )" per.ah ter,a+i : Upa)a -.t-k me."atasi :

$ Leher : Kekak-a.: ti+ak a+a N)eri;N)eri teka.: ti+ak a+a e.,'#a.;massa: ti+ak a+a Keter(atasa. "erak: e.a ,-"-#aris: ti+ak a+a pem(esara. Tir'i+ ti+ak a+a pem(eara.

Lime : ti+ak a+a pem(esara. Trakea : #-r-s Ke#-ha.: ti+ak a+a Upa)a -.t-k me."atasi:

$Da+a : e.t-k FFFFFFF Per"eraka. Da+a FFFFFFFF N)eri;.)eri teka. FFF Massa FFFF$ Pera+a."a. FF Takti# remit-s FFFF P'#a .aas FFFFFFFFFFFF /a.t-." : I.speksi

perk-si

pa#pasiFFFFFFFFFFFFFFFFFFFFF A-sk-#tasi FFFFFFFFFFFFFFFFFFF$$ Par- : I.speksi

perk-sipa#pasiFFFFFFFFFFFFFFFFFFFF$

A-sk-#tasi FFFFFFFFFFFFFFFFFFF!$ Pa)-+ara +a. ketiak :

e.,'#a.;massa : ti+ak a+a N)eri;.)eri teka. : ti+aka +a e."kak : pem(esara. .'rma# saat kehami#a. Kesimetrisa. : simetris

5$A(+'me. :I.speksi : mem(esar kare.a kehami#a. % (-#a.A-sk-#tasi : D// 152 ;me.it

Pa#pasi FFFFFFFFFFFFFFFFFFFFFFFF$$Perk-si FFFFFFFFFFFFFFFFFFFFFFFF$$ 8e.eta#ia :

I.speksi : terpasa." kateterPa#pasi : ti+ak a+a massa ata-p-. .)eri teka.Peremp-a. : Sik#-s me.tr-asi : .'rma#

K'.trasepsi : s-.tik3 (-#a. seka#i Kehami#a. : % (-#a. Ke#-ha. : p-si." +a. #emas3 m-a# m-.tah

Pria : Ke#-ha. 7$ Ekstremitas : Kek-ata. 't't : Atas: 5;5 awah: ka.a. !3 kiri 5

K'.trakt-r : ti+ak a+a Per"eraka. : ter(atas pa+a kaki ka.a.

De'rmitas : ti+ak a+a Pem(e."kaka. : pa+a ke+-a kaki E+ema : pa+a ke+-a kaki .)eri;.)eri teka. FFFFFF$ P-s;#-ka : a+a p-s pa+a kaki ka.a. )a." #-ka Re#eksre#eks Se.sasi

isep : < Ra(a;se.t-ha.:,emp'# kaki ka.a. ?Trisep : < pa.as : ,emp'# kaki ka.a. ?raki'ra+ia#is : < +i."i. : ,emp'# kaki ka.a. ?Pate##a : < teka.a.;t-s-k : ,emp'# kaki ka.a. ?A6hi#es : ,emp'# kaki ka.a. ?P#a.tar?(a(i.ski : ,emp'# kaki ka.a. ?

%$ K-#it +a. k-k- : ,emp'# ka.a. ter+apat ,ari."a. .ekr'sis ?#e(ih #e."kap

pa+a pe."ka,ia. #-ka

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P. Hasi# pemeriksaa. pe.-.,a."La('rat'ri-m :

Tanal / -kt#(er0

- 8-#a +arah sewakt- 200 m";+LTanal 1 -kt#(er 0

-

8-#a +arah se(e#-m maka. 250 m";+L- Pr'tei.-ria 2

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