ASUHAN KEPERAWATAN

PADA NY. M DIAGNOSA HIPERTENSI VERTIGO DI BANGSAL BAKUNG

RUANG 3 RSUD PANEMBAHAN SENOPATI BANTUL

A. PENGKAJIAN
Tanggal Pengkajian : 04 Juli 2014 Pukul : 14.18 WIB
Oleh : Aurora Daniar Aprodhita
I. IDENTITAS
a. Pasien
1. Nama : Ny. M
2. Tempat/tanggal lahir/umur : 13 Desember 1960 (58)
3. Jenis kelamin : Perempuan
4. Agama : Islam
5. Status perkawinan : Kawin
6. Pekerjaan : Ibu Rumah Tangga
7. Alamat : Gemahan RT 05, Bantul
8. Diagnosa medis : Hipertensi Vertigo
9. Tanggal masuk RS : 03 Juli 2018
b. Keluarga/ Penanggung Jawab
1. Nama : Ny. A
2. Umur : 36 tahun
3. Pendidikan : Lulus S1 PAI
4. Alamat : Gemahan RT 05, Bantul
5. Hubungan : Anak

II. HISTORY PATIENT

1. Patient Health
2. History Health Now
The patient says dizzy, limp, when staggering and blurred vision.

3. Past Health History

 The patient said he had been hospitalized twice,ever short of breath ± 1
year ago ,once fell ± 1 year ago, never had surgery , no family has
hereditary and congenital defects,65kg body weight 150 cm tall , no
history of drug and food allergies.

III. PHYSICAL EXAMINATION

a. General circumstances
1) KU : Comops Mentis
2) Nutritional status
- TB : 150 cm
- BB : 65 kg
- IMT : Obesitas
3) Vital sign
- Blood pressure : 170/90 mmHg
- Suhu : 36 C
- RR : 20x/menit
- Nadi : 90x/menit
B. ANALISA DATA
DATA MASALAH ETIOLOGI
DO : Nyeri kronis Penyakit Hipertensi
- Ny. M tampak Vertigo
menyeringai
- Ny. M tampak lemas
- TTV :
TD : 170/90 mmHg
S : 36 C
N : 90x/menit
R : 20x/menit

DS :
- The patient says dizzy
- The patient says if walking
the view is blurred and feels
 floating

C. DIAGNOSIS
1. Nyeri kronis berhubungan dengan penyakit

D. RENCANA KEPERAWATAN
No. Diagnosa Tujuan Intervensi Rasional
1. Chronic pain After 3x24 nursing 1. Observasi TTV 1. TTV normal
is related to actions are expected to 2. Teach
2. Help or control
disease reduce pain with the relaxation in diverting
pain, refocus
criteria: techniques
attention and
- The frequency 3. Educate can improve
coping
of pain patients about
3. So that patients
decreases hypertension and families
understand
- TTV Normal 4. Collaboration
about
- Klien dapat with doctors for hypertension
beristirahat administration of
4. Analgesic drugs
analgesic drugs can Helps reduce
the patient's pain

(Aurora)

E. PELAKSANAAN DAN EVALUASI

No Implementasi Evaluasi
1. Nursing actions are carried out on
Tuesday, 4 July 2018 At 09:15 a.m. on
the date that is :
1. train patients in relaxation
techniques and be comfortable with
deep breathing techniques
2. educate patients about hypertension
(aurora)
2. Pukul 17. 35 WIB
3. motivate and encourage patients
to perform deep breathing
techniques repeatedly if the
patient experiences pain
4. collaborate with doctors to
administer analgesic drugs as
indicated
(aurora)
3. Pukul 20.15 WIB
1. mengukur TTV, mengkaji tingkat
After taking action to train patients in deep
breath technique on 4th of July 2018
At 09.25 WIB the results were obtained :
S :patients say headache is reduced
O : - KU sedang, kesadaran Composmentis
- TD : 160/80 mmHg
- S : 36ºC
- N : 90 x/menit
- RR : 20 x/menit
Skala nyeri 3
A : Masalah nyeri kronis teratasi sebagian
P : Lanjutkan dengan :
1. motivate and encourage patients to
perform deep breathing techniques
repeatedly if the patient experiences
pain
2. collaborate with doctors to
administer analgesic drugs as
indicated
Pukul 17.50 WIB
S:
- the patient said that if it was painful,
the patient would repeat the deep
breath technique
- the patient said pain when injected
with analgesic drugs
- O :- KU sedang, kesadaran
Composmentis
- Skala nyeri 2
A : Masalah nyeri kronis teratasi sebagian
P : Lanjutkan dengan : . mengukur TTV
Pukul 20.20
S : Pasien mengatakan nyeri/pusing
nyeri pasien dan observasi ekspresi berkurang
wajah pasien O : - KU : baik, kesadaran Composmentis
( aurora ) - Skala nyeri 2
- TD : 170/90 mmHg
- S : 36, 6ºC
- N : 90 x/menit
- RR : 22 x/menit
A : Masalah nyeri akut teratasi sebagian
P : Lanjutkan intervensi dengan :
- Kelola program terapi
- Monitor KU + TTV