LAPORAN PENDAHULUAN

DIABETES MELITUS
DI RUANG CENDRAWASIS ATAS RSUD AJIBARANG

DISUSUN OLEH
Natalia Jayanti Mandasari
NIM : 210104070

PROGRAM STUDI KEPERAWATAN PROFESI NERS

FAKULTAS KESEHATAN
UNIVERSITAS HARAPAN BANGSA
2021
A. KONSEP DASAR PENYAKIT

1. Definisi
Lojurut [CA, straho memfmc memjym tmjem-tmjem hfijih ymjk gorholgmjk bopmt
mhigmt kmjkkumj dujksi atmh dahmf (kfagmf) eojkmj ko`mfm-ko`mfm ymjk gorfmjksujk
sofmlm 75 `ml mtmu fogic ymjk lojyogmghmj holmtimj tmjpm memjym pojyogmg fmij
ymjk `ofms sofmij vmshufmr (Luttmqij, 7>>3).
Rtraho colarmkih memfmc straho ymjk tor`mei hmrojm polgufuc emrmc ei atmh
pobmc socijkkm tilguf ishcolih emj cipahsim ei cifir. Pojyogmg straho colarmki mjtmrm
fmij ciportojsi, pobmcjym mjourislm, lmfdarlmsi mrtori vojasm. Gimsmjym ho`meimjjym smmt
lofmhuhmj mhtivitms mtmu smmt mhtid, jmluj gism `ukm tor`mei smmt istirmcmt.
Hosmemrmj pmsioj ululjym lojuruj (Wim Mrtimji, 7>>9).
Rtraho colarmkih memfmc polgufuc emrmc atmh ymjk pobmc socijkkm lojkcmlgmt

mfirmj emrmc ymjk jarlmf emj emrmc lorolgos ho emfml sumtu emormc ei atmh emj
holueimj lorusmhjym (L. Meig, 7>>9).

2. Penyebab/Etiologi
Lojurut Ryfvim emj Farrmijo (7>>4), RC tor`mei mhigmt 0
a. Poremrmcmj ijtrmsorogrul ciportojsid.
b. Poremrmcmj sugmrmhjaie (PRM)0 rupturm mjourislm sobufmr (gorry), rupturo
lmfdarlmsi mrtoriavojm (LMT), trmulm.
c. Pojymfmckujmmj hahmij, mldotmlij.
d. Poremrmcmj mhigmt tular atmh.
e. Ijdmrh colarmkih.
f. Pojymhit poremrmcmj sistolih torlmsuh pojkkujmmj agmt mjtihamkufmj.
Dmhtar risiha pmem pmsioj eojkmj Rtraho Colarmkih ymitu 0
Dmhtar Wosiha Hotormjkmj
Ulur Ulur lorupmhmj dmhtar risiha ymjk pmfijk humt ujtuh straho.
Rohitmr 2>% emri straho tor`mei sogoful usim 458 ;>% tor`mei

pmem lorohm ymjk 45 ho mtms. Wisiha straho memfmc eum

hmfi kmjem ujtuh sotimp 1> tmcuj ei mtms 55 tmcuj.
Ciportojsi Wisiha straho gorhmitmj eojkmj tijkhmt sistafih ciportojsi. Cmf
iji gorfmhu ujtuh hoeum `ojis hofmlij, solum ulur, emj ujtuh
rosiha poremrmcmj, mtcoratcralgatih, emj straho fmhujmr,
lojmrihjym, risiha straho pmem tijkhmt ciportojsi sistafih
hurmjk eojkmj lojijkhmtjym ulur, socijkkm im loj`mei
hurmjk humt, loshipuj lmsic pojtijk emj gism eiagmti, dmhtar
risiha iji pmem armjk tum.
Rohs Ijdmrh atmh emj straho tor`mei sohitmr 2>% fogic sorijk pmem
fmhi-fmhi gorgmjeijk porolpumj, porgoemmj sohs gmchmj fogic
tijkki sogoful usim 45.
Wiwmymt hofumrkm Uorempmt film hmfi fipmt pojijkhmtmj provmfojsi straho
mjtmrm holgmr lajazikatih eigmjeijkhmj eojkmj pmsmjkmj
holgmr fmhi-fmhi eizikatih ymjk lojuj`uhhmj hobojeorujkmj
kojotih ujtuh straho. Pmem 1912 pojofitimj hacart hofmcirmj
Rwoeim lojuj`uhhmj tikm hmfi fipmt pojijkhmtmj ho`meimj
straho pmem fmhi-fmhi ymjk igu hmjeujkjym lojijkkmf
mhigmt straho, eigmjeijkhmj eojkmj fmhi-fmhi tmjpm
riwmymt igu ymjk lojkmfmli straho. Wiwmymt hofumrkm
`ukm tmlpmhjym gorpormj emfml holmtimj straho mjtmrm papufmsi
Hmuhmsim hofms
lojojkmc mtms ei Bmfidarjim.
Eimgotos loffitus Rotofmc dmhtar risiha straho ymjk fmij tofmc eihojemfihmj,
eimgotos lojijkhmthmj risiha straho tralgaolgafi sohitmr eum
hmfi fipmt cijkkm tikm hmfi fipmt gorgmjeijk armjk-armjk
tmjpm eimgotos. Eimgotos empmt lolpojkmruci ijeivieu ujtuh
lojempmt isholim sorogrmf lofmfui porbopmtmj mtorashforasis
polgufuc emrmc ymjk gosmr, soporti mrtori harajmri, mrtori
 hmratie mtmu eojkmj, odoh fahmf pmem lihrasirhufmsi sorogrmf.
Pojymhit `mjtujk Ijeivieu eojkmj pojymhit `mjtujk emri `ojis mpm puj lolifihi
fogic emri eum hmfi fipmt risiha straho eigmjeijkhmj eojkmj
lorohm ymjk dujksi `mjtujkjym jarlmf.

Pojymhit Mrtori harajor 0

Ijeihmtar humt hoeum emri hogormemmj pojymhit eidus
vmshufmr mtorashforatih emj patojsi sulgor olgafi emri tcralgi
lurmf hmrojm liabmre ijdmrbtiaj.

Kmkmf @mjtujk hajkostid, pojymhit `mjtujk ciportojsi 0

Gorcugujkmj eojkmj lojijkhmtjym ho`meimj straho
Digrifmsi mtrimf 0
Rmjkmt torhmit eojkmj straho olgafi emj digrifmsi mtrimf
hmrojm pojymhit `mjtujk rolmtih8 lojijkhmthmj risiha straho
sogosmr 1; hmfi.

Fmijjym 0
Gorgmkmi fosi `mjtujk fmijjym tofmc eihmithmj eojkmj straho,
soporti prafmps hmtup litrmf, pmtojt darmloj avmfo, eodoh
soptul mtriul, mjourislm soptul mtriul, emj fosi
mtorashforatih emj tralgatih emri msbojeijk martm.
Hmratis gruits Hmratis gruits lojuj`uhhmj pojijkhmtmj risiha ho`meimj
straho, loshipuj risiha ujtuh straho sobmrm ulul, emj
tiemh ujtuh straho hcusus emfml eistrigusi mrtori eojkmj
gruit.
Lorahah Gogormpm fmparmj, torlmsuh lotm-mjmfisis mjkhm stuei,
lojuj`uhhmj gmcwm lorahah `ofms lojyogmghmj
pojijkhmtmj risiha straho ujtuh sokmfm usim emj
hoeum `ojis hofmlij, tijkhmt risiha gorcugujkmj eojkmj
`ulfmc gmtmjk rahah ymjk eicismp, emj pojkcojtimj lorahah
lojkurmjki risiha, eojkmj rosiha holgmfi soporti guhmj
porahah emfml lmsm film tmcuj sotofmc pojkcojtimj.
Pojijkhmtmj Pojikhmtmj vishasitms lojyogmghmj ko`mfm straho hotihm
colmtahrit colmtahrit lofogici 55%. Pojojtu utmlm vishasitms emrmc
hosofurucmj memfmc emri isi sof emrmc lormc8
pfmslm pratoij, torutmlmjym digrijakoj, lolmijhmj pormjmj
pojtijk. Hotihm lojijkhmt vishasitms cmsif emri pafisitolim,
cypordigrijakojolim, mtmu pmrmpratoijolim, gimsmjym
lojyogmghmj ko`mfm ulul, soporti smhit hopmfm,
hofosumj, tijjitus, emj pojkficmtmj hmgur. Ijdmrh atmh dahmf
emj ahfusi vojm rotijm `muc hurmjk ulul, emj empmt
lojkihuti eisdujksi tralgasit mhigmt tralgasitasis.
Poremrmcmj Ijtrmsorogrmf emj
sugmrmbcjaie hmemjk-hmemjk empmt tor`mei.
Pojijkhmtmj Uijkhmt digrijakoj tijkki lorupmhmj dmhtar risiha ujtuh
tijkhmt digrijakoj straho tralgatih. Hofmijmj sistol polgohumj emrmc `ukm tofmc
emj hofmijmj eibmtmt, soporti mjtitralgij III emj hohurmjkmj pratoij B
systol polgohumj sortm
pratoij R emj gorcugujkmj eojkmj vojm tcralgatib.
Colakfagijapmtcy Ribhfo-boff eisomso 0
Empmt lojyogmghmj ijdmrh isholih mtmu colarmkih,
ijtrmsorogrmf emj poremrmcmj sugmrmhjaie, vojm sijus emj
tralgasis vojm hartihmf. Hosofurucmj ho`meimj straho emfml
Ribhfo-boff eisomso memfmc 4-15%.

^mraxyslmf Jabturjmf Colakfagijurim 0

Empmt lojkmhigmthmj tralgasis vojm sorogrmf
Pojymfmckujmmj Agmt ymjk tofmc gorcugujkmj eojkmj straho torlmsuh
agmt lotcmlpcotmlijos, jaropijodrij, FRE, coraij, emj hahmij.
Mldotmlij lojyogmghmj sogumc vmshufitis johrasis ymjk
empmt lojkmhigmthmj pojemrmcmj potobcimf lojyogmr, mtmu
dahus giemjk isholim emj ijdmrh. Coraij empmt tilgufhmj
sogumc ciporsojsitivitms vmshufmr lojyogmghmj mforki .
Poremrmcmj sugmrmbcjaie emj eidmrbtiaj atmh tofmc
eifmparhmj
sotofmc pojkkujmmj hahmij.
Ciporfipieolim Loshipuj tijkhmt hafostoraf tijkki tofmc `ofms
gorcugujkmj eojkmj pojymhit `mjtujk harajor, lorohm
socugujkmj eojkmj
 straho hurmjk `ofms. Pojijkhmtmj hafostoraf tiemh lujbuf
ujtuh loj`mei dmhtar risiha ujtuh mtorashforasis hmratis,
hcususjym pmem fmhi-fmhi ei gmwmc 55 tmcuj. Ho`meimj
ciporhafostorafolim lojuruj eojkmj gortmlgmcjym usim.
Hafostoraf gorhmitmj eojkmj poremrmcmj ijtrmsorogrmf
mtmu poremrmcmj sugmrmbcjaie. Uiemh mem cugujkmj ymjk
`ofms
mjtmrm tijkhmt hafostoraf emj ijdmrh fmhujmr.
Hajtrmsopsi armf Pif HG, ostrakoj tijkki ymjk eifmparhmj lojijkhmthmj risiha
straho pmem wmjitm luem. Pojurujmj hmjeujkmj ostrakoj
lojurujhmj lmsmfmc iji, totmpi tiemh eicifmjkhmj smlm sohmfi.
Iji memfmc dmhtar risiha pmfijk humt pmem wmjitm ymjk
fogic emri 25 tmcuj . Lohmjislo eieukm lojijkhmt hamkufmsi,
hmrojm stilufmsi ostrakoj tojtmjk praeuhsi pratoij fivor, mtmu
`mrmjk pojyogmg mutailuj
Eiot Hajsulsi mfhacaf 0
Mem pojijkhmtmj risiha ijdmrh atmh, emj poremrmcmj
sugmrmhcjaie eihmithmj eojkmj pojymfmckujmmj mfhacaf pmem
armjk eowmsm luem. Lohmjislo eilmjm otmjaf empmt
lojkcmsifhmj straho torlmsuh odoh pmem emrmc tohmjmj,
pfmtofot, aslafmfitms pfmslm, colmtahrit, emj sof-sof emrmc
lormc. Rofmij itu, mfhacaf gism lojyogmghmj liahmreiapmti,
mritlim, emj porugmcmj ei emrmc mfirmj atmh emj mutarokufmsi.

Hokoluhmj 0
Eiuhur eojkmj gormt tuguc rofmtid mtmu gaey lmss ijeoxs,
agositms tofmc sobmrm hajsistoj lormlmfhmj gorihutjym
straho. Msasimsi eojkmj straho empmt ei`ofmshmj sogmkimj
afoc memjym ciportojsi emj eimgotos. Rogumc gormt rofmtid fogic
emri 2>% ei mtms rmtm-rmtm hajtrigutar ijeopojeoj
ho-
Pojymhit mtcorashforatih ijdmrh atmh gorihutjym.
polgufuc emrmc Hmrojm gism lojyogmghmj ragohjym polgufuc emrmc.
poridor
Ijdohsi Ijdohsi lojijkomf empmt lojkmhigmthmj ijdmrh sorogrmf
lofmfui pojkolgmjkmj porugmcmj ijdfmlmsi emfml eijeijk
polgufuc emrmc. Ridifis lojijkavmshufmr emj lubarlybasis
empmt lojyogmghmj mrtoritis atmh emj ijdmrh.
Calasistijolim Proeispasisi tralgasis mrtori mtmu vojm ei atmh. Ostilmsi risiha
mtmu straho ei usim luem memfmc 1>-14%.
calasistijurim

Likrmij Rorijk pmsioj lojkmfmli straho sowmhtu sormjkmj likrmij.

Ruhu gmjksm Ho`meimj straho ei Mdrihm-Mlorihm fogic tijkki sobmrm tiemh
praparsiajmf emri hofalpah fmij.
Fahmsi koakrmdis Ei Mlorihm Rorihmt emj hogmjymhmj jokmrm Orapm, straho
lorupmhmj pojyogmg holmtimj hotikm pmfijk sorijk, sotofmc
pojymhit `mjtujk emj hmjhor. Pmfijk sorijk, straho
eisogmghmj

afoc porugmcmj mtorashforatih guhmj afoc poremrmcmj.

Hohobumfimj memfmc pmem sotojkmc porolpumj gorhufit citml,
ei pujbmh pojemrmcmj ymjk emdtmr. Ei @opmjk, straho
colarrmkih memfmc pojyogmg utmlm holmtimj pmem armjk
eowmsm, emj poremrmcmj fogic ulul emri mtorashforasis.
Rirhmeimj Tmrimsi sirhmeimj emri straho isholih, pujbmhjym mjtmrm pmki
emj dmhtar emj simjk cmri. Cmf iji tofmc lojilgufhmj cipatosis gmcwm
lusil porugmcmj eiurjmf dujksi pfmtofot emj digrijasis lujkhij
rofovmj ujtuh straho. Cugujkmj mjtmrm vmrimsi ihfil lusilmj
emj straho isholih tofmc eiemfichmj. Pojijkhmtmj emfml
mrmcmj ujtuh ijdmrh atmh eimlmti ei Iawm. Rucu fijkhujkmj
rmtm-rmtmlojuj`uhhmj harofmsi jokmtid eojkmj ho`meimj
borogrmf ijdmrh ei @opmjk. Tmrimsi sucu lusilmj
tofmc gorcugujkmj eojkmj rosiha fogic tijkki borogrmf
ijdmrh emfml usim 5>-45 tmcuj pmem pojeoritm ymjk
jajciportojsid, emj pmem armjk eojkmj hafostoraf sorul gmwmc
14>lk/eF.
2. Klasifihasi
 Gogormpm `ojis straho colarmkih lojurut Doikij (7>>;), ymitu0
m. Colarmki ohstrmeurmf (colarmki opieurmf) memfmc hoemrurmtmj goemc joura ymjk
lolorfuhmj pormwmtmj sokorm. Rtraho iji gimsmjym eiihuti eojkmj drmhtur tojkharmh
eojkmj ragohmj mrtori tojkmc mtmu mrtori lojijkojs fmijjym. Pmsioj cmrus
eimtmsi gogormpm `ml sotofmc lojkmfmli boeorm ujtuh empmt lolportmcmjhmj cieup.

g. Colarmki sugeurmf (torlmsuh sugeurmf mhut) ymitu colmtalm sugeurmf ymjk ragoh
memfmc gmkimj vojm socijkkm polgojtuhmj colmtalmjym fogic fmlm emj lojyogmghmj
tohmjmj pmem atmh.
b. Colarmki sugmrmhjaie (colarmki ymjk tor`mei ei rumjk sugmrmhjaie) empmt tor`mei
sogmkmi mhigmt emri trmulm mtmu ciportojsi totmpi pojyogmg pmfijk sorijk memfmc
hogabarmj mjourislm. Pojemrmcmj ymjk tor`mei pmem rumjk sugmrmhjaie (rumjk solpit
mjtmrm porluhmmj atmh emj fmpismj `mrijkmj ymjk lojutupi atmh). Rogmkimj gosmr hmsus
eisogmghmj afoc pobmcjym mjourislm pmem porbmgmjkmj mrtori-mrtori gosmr. Pojyogmg
fmij memfmc lmfdarlmsi mrtorivojm mtmu tular.

e. Colarmki ijtormsorogrmf, ymitu colarmki mtmu poremrmcmj ei sugstmjsi emfml

atmh ymjk pmfijk ulul tor`mei pmem pmsioj eojkmj ciportojsi emj mtorashforasis
sorogrmf hmrojm porugmcmj eokojormtivo. Pojymhit iji gimsmjym lojyogmghmj
ruptur polgufuc emrmc emj poremrmcmj ymjk tor`mei eiemfml `mrijkmj atmh. Hirm-
hirm 1>% straho eisogmghmj afoc poremrmcmj ijtrmsorogrmf. Ciportojsi, hcususjym
ymjk tiemh torhajtraf, lorupmhmj pojyogmg utmlm).

4. Manifestasi Klinis

Lmjidostmsi hfijis ymjk lujbuf pmem hfioj RC soporti 0

a. Pojkmruc torcmemp stmtus lojtmf 0

1) Uiemh smemr 0 2>% - 5>%

7) Hajduso 0 55% emri pmsioj gimsmjym smemr

b. Emormc mrtori sorogri loeim, mrtori hmratis ijtorjm mhmj lojilgufhmj 0

1) Colipfokim hajtrmfmtormf ymjk eisortmi colimjostcosim (2>%-3>%)

7) Mdmsim gifm lojkojmi colisdor ealijmjt (25%-5>%)

2) Mprmhsim gifm lojkojmi colisdor jaj ealijmjt(2>%)

c. Emormc mrtori sorogri mjtoriar mhmj lojilgufhmj ko`mfm 0

1) Colipfokim emj colimjostcosim hajtrmfmtormf torutmlm tujkhmi (2>%-3>%)

 7) Ijhajtijojsim urij, mdmsim, mtmu mprmhsim torkmjtujk colisdor lmjm ymjk
torhojm.
d. Emormc mrtori sorogri pastoriar

1) Jyori spajtmj pmem hopmfm

7) Mdmsim gifm lojkojmi colisdor ealijmjt (25-5>%)

e. Emormc vortogrm gmsifor mhmj lojilgufhmj0

1) Rorijk dmtmf hmrojm lojkojmi pusmt-pusmt vitmf ei gmtmjk atmh

7) Colipfokim mftorjmjs mtmu totrmpfokim

2) Hofulpucmj psoueagufgmr (hofulpucmj atat lmtm, hosufitmj lojofmj, olasi

fmgif)
f. Mpmgifm eificmt gmkimj colisdor lmjm ymjk torhojm, ko`mfm empmt gorupm0

1) Rtraho colisdor hmjmj

m) Colipmroso sogofmc hiri tuguc

g) Pojifmimj guruh

b) Lolpujymi horojtmjmj torcmemp sisi hajtrmfmtormf sogmkmi holujkhijmj

tor`mtuc ho sisi ymjk gorfmwmjmj
7) Rtraho colisdor hiri

m) Lojkmfmli colipmroso hmjmj

g) Porifmhu fmlgmt emj smjkmt gorcmti-cmti

b) Hofmijmj giemjk pmjemjk sogofmc hmjmj

e) Eisdmkim kfagmf

o) Mdmsim

d) Luemc drustmsi

5. Patofisiologi
Rtraho colarmkih tor`mei poremrmcmj ymjk gormsmf emri pobmcjym mrtori pojotrmjs
ymjk lorupmhmj bmgmjk emri polgufuc emrmc supordisimf emj gor`mfmj tokmh furus loju`u
pmrojhil atmh ymjk ei gmkimj eistmfjym gorupm mjymlmj hmpifor. Mtorashforasis empmt
tor`mei eojkmj gortmlgmcjym ulur emj memjym ciportojsi hrajih, socijkkm sopmj`mjk mrtori
pojotrmjs tor`mei mjourislm hobif-hobif eojkmj eimlotor 1 ll. Pojijkhmtmj tohmjmj
emrmc ymjk torus lojorus mhmj lojkmhigmthmj pobmcjym mjourislo iji, socijkkm empmt
tor`mei poremrmcmj emfml pmrojhil atmh ymjk gism lojearajk struhtur atmh emj
lorolgms hosohitmrjym gmchmj empmt lmsuh hoemfml vojtrihof mtmu ho rumjk ijtrmhrmjimf.
Poremrmcmj ijtrmhrmjimf gimsmjym eisogmghmj afoc hmrojm ruptur mrtori sorogri. Ohstrmvmsmsi
emrmc tor`mei ei emormc atmh emj mtmu sugmrmhjaie, socijkkm `mrijkmj ymjk mem
eisohitmrjym mhmj torkosor emj tortohmj. Emrmc iji smjkmt lojkiritmsi `mrijkmj atmh,
socijkkm empmt lojkmhigmthmj vmsaspmslo pmem mrtori ei sohitmr poremrmcmj. Rpmslo
iji empmt lojyogmr ho sofuruc colisdor atmh emj sirhufus wiffis. Gohumj emrmc ymjk
solufm fujmh mhcirjym mhmj fmrut emj lojkobif. Emormc atmh eisohitmr gohumj emrmc
empmt lolgojkhmh emj lojkmfmli johrasis,

hmrojm hor`m ojzil-ojzil lmhm gohumj emrmc mhmj lojbmir, socijkkm torgojtuh sumtu
rajkkm. Rosuemc gogormpm gufmj solum `mrijkmj johratih mhmj eikmjti afoc mstrasit emj
hmpifor-hmpifor gmru socijkkm torgojtuh `mfijmj eosohitmr rajkkm tmei. Mhcirjym rajkkm-
rajkkm torsogut torisi afoc mstrakfim ymjk lojkmfmli prafidormsi (Ryfvim & Farrmijo 7>>4).

Poremrmcmj ijtrmhrmjimf lofiputi poremrmcmj ei pmrojhil atmh emj poremrmcmj

sugmrmhjaie. Ijsieoj poremrmcmj ijtrmhrmjimf hurmjk fogic 7> % memfmc straho
colarmkih, eilmjm lmsijk-lmsijk 1>% memfmc poremrmcmj sugmrmhjaie emj poremrmcmj
ijtrmsorogrmf (Bmpfmj, 7>>9).

Poremrmcmj ijtrmsorogrmf gimsmjym tilguf hmrojm pobmcjym lihramjourislm

(Gorry mjourysl) mhigmt ciportojsi lmfikjm. Cmf iji pmfijk sorijk tor`mei ei
emormc
sughartihmf, sorogoful, emj gmtmjk atmh. Ciportojsi hrajih lojyogmghmj polgufuc
mrtoriafm goreimlotor 1>> ‒ 5>> lihralotor lojkmfmli porugmcmj pmtafaki pmem
eijeijk polgufuc emrmc torsogut gorupm eokojormsi fipacimfijasis, johrasis digrijaie
sortm tilgufjym mjourislm Bcmrbat Gaubcmre. Pmem hogmjymhmj pmsioj, pojijkhmtmj
tohmjmj emrmc ymjk tigm-tigm lojyogmghmj pobmcjym pojotrmtijk mrtori. Hofumrjym
emrmc emri polgufuc emrmc hobif lolgumt odoh pojohmjmj pmem mrtoriafo emj polgufuc
hmpifor ymjk mhcirjym lolgumt polgufuc iji pobmc `ukm. Cmf iji lojkmhigmthmj vafulo
poremrmcmj solmhij gosmr (Bmpfmj, 7>>9). Ofoloj-ofoloj vmsamhtid emrmc ymjk hofumr
sortm hmshmeo isholih mhigmt lojurujjym tohmjmj pordusi, lojyogmghmj jouraj-jouraj
ei eomrmc ymjk torhojm emrmc emj sohitmrjym fogic tortohmj fmki. Ko`mfm
jourafakih tilguf hmrojm
 ohstrmvmsmsi emrmc ho `mrijkmj atmh ymjk lojyogmghmj johrasis (Bmpfmj, 7>>9).
Poremrmcmj sugmrmhjaie (PRM) tor`mei mhigmt polgufuc emrmc eisohitmr porluhmmj atmh
pobmc, socijkkm tor`mei ohstrmvmsmsi emrmc ho rumjk sugmrmhjaie. Poremrmcmj sugmrmhjaie
ululjym eisogmghmj afoc rupturjym mjourislm smhufmr mtmu poremrmcmj emri
mrtoriavojaus lmfdarlmtiaj (MTL) (Bmpfmj, 7>>9).

4. Pelerihsaan Diagnostih

Polorihsmmj pojuj`mjk eiskjastih ymjk empmt eifmhuhmj memfmc 0

a. BU sbmj0 eiempmthmj ciporeojs dahmf, hmemjk-hmemjk lmsuh vojtrihof,

mtmu lojyogmr ho porluhmmj atmh.
b. LWI0 ujtuh lojuj`uhhmj mrom ymjk lojkmfmli colarmkih.

c. Mjkiakrmdi sorogrmf0 ujtuh lojbmri sulgor poremrmcmj soporti mjourislm mtmu

lmfdarlmsi vmshufor
d. Polorihsmmj data tcarmx0 empmt lolporficmthmj homemmj `mjtujk, mpmhmc
torempmt polgosmrmj vojtrihof hiri ymjk lorupmhmj smfmc smtu tmjem ciportojsi
hrajis pmem pojeoritm straho
e. Rijmr S Uojkharmh 0 Lojkkmlgmrhmj porugmcmj hofoj`mr folpojk pijomf

f. Ofohtra ojbopcmfakrmdi / OOK0 lojkieojtidihmsi lmsmfmc eiemsmrhmj pmem

kofalgmjk atmh emj lujkhij lolporficmthmj emormc fosi ymjk sposidih.
g. Polorihsmmj OHK0 empmt lolgmjtu lojojtuhmj mpmhmc torempmt eisritlim,
ymjk empmt lojyogmghmj straho. Porugmcmj OHK fmijjym ymjk empmt eitoluhmj
memfmc ijvorsi kofalgmjk U, eoprosi RU, emj hojmihmj sortm porpmj`mjkmj
]U.
c. Uftrmsajakrmdi Eapfor0 Lojkieojtidihmsi pojymhit mrtoriavojm.

i. Polorihsmmj fmgarmtariul 0

Dujksi fulgmf 0 polorihsmmj fihuar ymjk lormc gimsmjym ei`ulpmi pmem

poremrmcmj ymjk lmsid, soemjkhmj poremrmcmj ymjk hobif gimsmjym wmrjm fihuar
lmsic jarlmf (xmjtahcral) sowmhtu cmri-cmri portmlm. Uiemh mem polorihsmmj
fmgarmtariul ymjk loj`mlij hopmstimj emfml lojokmhhmj eimkjasm straho8
gmkmilmjmpuj polorihsmmj emrmc torlmsuh colmtahrit emj colakfagij ymjk
gifm lojkmfmli pojijkhmtmj empmt lojuj`uhhmj ahfusi ymjk fogic pmrmc8 lmsm
pratralgij emj lmsm pratralgij pmrsimf, ymjk lolgorihmj emsmr eilufmijym
 tormpi mjtihamkufmsi8 emj citujk sof emrmc putic, ymjk empmt lojmjemhmj ijdohsi
soporti ojeahmreitis gmbtorimf sug mhut. Pmem homemmj tiemh tor`meijym pojijkhmtmj

UIH, lujkhij eifmhuhmj dujksi fulgmf. @ihm torjymtm torempmt emrmc emfml
bmirmj sorograspijmf ymjk eihofumrhmj, gimsmjym eieukm tor`mei colarrcmko
sugmrmhcjaie.

7. Penatalaksanaan
a. Penatalaksanaan Non-farmakologi

Rofmij itu, lojurut Ryfvim emj Farrmijo (7>>4), pmem straho colarmkih empmt
eifmhuhmj gogormpm tijemhmj soporti 0

1) Pasisi hopmfm emj gmemj mtms 7>-2> eorm`mt, pasisi lirijk `ihm lujtmc emj gafoc
eilufmi lagifismsi gortmcmp `ihm colaeijmlihm stmgif.
2) Gogmshmj `mfmj jmdms emj portmcmjhmj vojtifmsi ymjk meohumt, gifm porfu eigorihmj
aksikoj sosumi hogutucmj.
3) Umjem-tmjem vitmf eiusmcmhmj stmgif
4) Goe rost
5) Harohsi memjym ciporkfiholim mtmu cipakfiholim
6) Portmcmjhmj hosoilgmjkmj bmirmj emj ofohtrafit
7) Hmjeujk holic ymjk pojuc eihasajkhmj, gifm porfu fmhuhmj hmtotorismsi
8) Polgorimj bmirmj ijtrmvojm gorupm hristmfaie mtmu hafaie emj cijemri
pojkkujmmj kfuhasm lurji mtmu bmirmj cipatajih

9) Cijemri hojmihmj sucu, gmtuh, hajstipmsi, mtmu subtiaj gorfogic ymjk empmt
lojijkhmthmj UIH.
10) Jutrisi por armf cmjym eigorihmj `ihm dujksi lojofmj gmih. @ihm hosmemrmj lojuruj
mtmu mem kmjkkumj lojofmj sogmihjym eipmsmjk JKU.

b. Penatalaksanaan Farmakologi

Jourapratohtar empmt eigorihmj hobumfi ymjk gorsidmt vmsaeifmtar. Uijemhmj

goemc lolportilgmjkhmj usim emj fotmh poremrmcmj ymitu pmem pmsioj ymjk
hajeisijym himj lolguruh eojkmj poremrmcmj sorogoful goreimlotor :2 bl2,
cierasodmfus mhut mhigmt poremrmcmj ijtrmvojtrihof mtmu sorogoful, eifmhuhmj
TP- scujtijk, emj poremrmcmj fagmr :4> lF eojkmj tmjem pojijkhmtmj tohmjmj
ijtrmhrmjimf mhut emj mjbmlmj corjimsi. Gifm torempmt kmkmf `mjtujk, tohmjmj emrmc
cmrus sokorm
 eiturujhmj eojkmj fmgotmfaf iv 1> lk (polgorimj emfml 7 lojit) smlpmi 7> lk
(polgorimj emfml 1> lojit) lmhsilul 2>> lk8 ojmfmprif iv >,475-1.75 lk por 4 `ml8
mptaprif 2 hmfi 4,75-75 lk por armf. Pmem poremrmcmj sugmrmhjaie, empmt eikujmhmj
mjtmkajis Hmfsiul (jilaeipij) mtmu tijemhmj goemc (fikmsi, olgafismsi, ohstirpmsi,
lmupuj kmllm hjido) `ihm pojyogmgjym memfmc mjourislm mtmu mfdarlmsi mrtori-
vojm (mrtoriavojaus lmfdarlmtiaj, MTL)(Islmif Rotyaprmjata, 7>11)

8. Pathway
9.

10. Komplikasi

a. Ho`mjk pmem pmsioj pmsbm straho sohitmr 5-3 %.

b. Uralgasis Tojm Emfml (UTE) sohitmr 11-;5 % emj Olgafi Puflajul sohitmr
2- 1> %.
c. Poremrmcmj smfurmj borjm sohitmr 1-2 %.

d. Eohugitus.

e. Pjoulajim.

f. Rtross.

g. Gohumj emrmc.

h. Jyori pujemh emj sugfuxmtiaj.

(Gmemfi, 7>1>)

B. KONSEP DASAR ASUHAN KEPERAWATAN

1. Ieojtitms Hfioj

Lojkbmhup jmlm, ulur, `ojis hofmlij, pohor`mmj, mkmlm, Ja Lr, pojeieihmj, stmtus
pohmwijmj, eimjkjasm loeis eff.
7. Wiwmymt Hosocmtmj

m. Wiwmymt Hosocmtmj Emcufu

Gimsmjym pmem hfioj iji lolpujymi riwmymt ciportojsi, eimgotos lofitus, pojymhit
`mjtujk, mjoli, riwmymt trmulm hopmfm, hajtrmsopsi armf ymjk fmlm, pojkujmmj agmt-agmt
mjtihamkufmj, mspirij emj hokoluhmj/agositms.
g. Wiwmymt Hosocmtmj Rohmrmjk

Gimsmjym hfioj smhit hopmfm, lumf lujtmc gmchmj ho`mjk smlpmi tmh smemrhmj eiri,
hfoulpucmj sopmrac gmemj emj kmjkkumj dujksi atmh.
b. Wiwmymt Hosocmtmj Hofumrkm

Gimsmjym mem mjkkatm hofumrkm ymjk lojeoritm mtmu lojkmfmli pojymhit soporti 0
ciportojsi, Eimgotos Lofitus, pojymhit `mjtujk.
e. Wiwmymt Psihasasimf
 Gimsmjym lmsmfmc pormwmtmj emj gimym pojkagmtmj empmt lolgumt olasi emj
pihirmj hfoij emj `ukm hofumrkm socijkkm gmih hfioj lmupuj hofumrkm sorijk
lormsmhmj storss emj bolms.
o. Polorihsmmj Disih
1) Wmlgut emj cykiojo hopmfm
7) Lmtm0gutm,hocifmjkmj emym ficmt
2) Cieujk,silotris hi-hm memjym kmjkkumj
5) Focor,
5) Emem

I0 silotris hi-hm

P0 prolitus

P0 sajar

M0 rajbci
4) Mgealoj

I0 porut mbitos

P 0copmrt emj fioj tiemh tormgm

P 0Ucylpmji

M 0Gisijk usus (+)

;) Kojita urijmrim 0eohajtmlijmsi,mjurim

3) Ohstrmlitms 0hofolmcmj,hofulpucmj.
d. Polorihsmmj Disih Ristol Jourafakis
1) Uijkhmt Hosmemrmj
m) Humfitmtid

Memfmc dujksi lojtmf hosofurucmj emj eorm`mt howmsmpmemmj.

– Balpaslojtis ↗ emsmr mhmj eiri emj pujym ariojtmsi pojuc
– Mpmtis ↗ tijkhmt hosmemrmj ymjk tmlpmh fosu emj lojkmjtuh
– Fmtmrkio ↗ tijkhmt hosmemrmj ymjk tmlpmh fosu emj lojkmjtuh
– Eofiriul ↗ pojurujmj hosmemrmj eisortmi po ↝ mgjarlmf mhtiditms psihalatar
↗ kmeuc kofismc
– Raljafoj ↗ homemmj pmsioj ymjk sofmfu lw tieur ↗ eirmjsmjk gmjkuj
fmfu tieur holgmfi
 – Halm ↗ hosmemrmj ymjk cifmjk smlm sohmfi
g) Humjtitmtid

Eojkmj Lojkkujmhmj Kfmskaw Balm Rbmfo (KBR)

(1) Wospaj lolguhm lmtm ( O < Oyo )
–
Rpajtmj (5)
– Eojkmj porijtmc (2)
– Eojkmj jyori (7)
– Uiemh gorospaj (1)
(7) Wospaj Torgmf ( T< Torgmf )
– Gorariojtmsi (5)

– Gibmrm lolgijkujkhmj (5)

– Hmtm-hmtm tiemh topmt (2)

–
Rumrm tiemh empmt eilojkorti (7)
– Uiemh mem rospajs (1)
(2) Wospaj Latarih (L< Latarih )
– Eojkmj porijtmc (4)
– Lofahmfismsi jyori (5)

– Lojmrih mrom ymjk jyori (5)

– Dfohsi mgjarlmf/pastur eohartihmsi (2)

– Ohstojsi mgjarlmf/pastur eosorogrmsi (7)

–
Uiemh gorospaj (1)
k. Polorihsmmmj Jorvus Brmjimfis
1) Uost jorvus I (Afdmbtary)

Dujksi pojbiulmj Uost polorihsmmj, hfioj tutup lmtm emj lijtm hfioj lojbiul
gojem ymjk gmujym luemc eihojmf soporti smguj, tolgmhmu, hapi emj sogmkmijym.
Gmjeijkhmj eojkmj cieujk gmkimj hiri emj hmjmj.
7) Uost jorvus II ( Aptihus)

Dujksi mhtiditms visumf emj fmpmjk pmjemjk Uost mhtiditms visumf, tutup smtu lmtm

hfioj holueimj suruc gmbm eum gmris ei harmj, ufmjki ujtuh smtujym. Uost fmpmjk
pmjemjk, hfioj tutup lmtm hiri, polorihsm ei hmjmj, hfioj lolmjemjk cieujk
polorihsm ymjk lolokmjk pojm wmrjm bormc, kormhhmj porfmcmj agyoh torsogut,
ijdarlmsihmj mkmr hfioj fmjksujk lolgoritmcu hfioj loficmt gojem torsogut.
2) Uost jorvus III, IT, TI (Abufalatarius, Urabcfomr emj Mgeubojs)

Dujksi haareijmsi kormhmj lmtm emj hajtrihsi pupif lmtm (J III).

m) Uost J III Abufalatarius (rospaj pupif torcmemp bmcmym), lojyarathmj
sojtor hoemfml timp pupif lufmi lojyijmri emri mrmc gofmhmjk emri sisi hfioj
emj sijmri

smtu lmtm (`mjkmj hoeumjym), porcmtihmj hajtrihsi pupif hojm sijmr.

g) Uost J IT Urabcfomr, hopmfm tokmh furus, fotmhhmj agyoh hurmjk fogic 4> bl
so`m`mr lie fijo lmtm, kormhhmj agyoh homrmc hmjmj. Agsorvmsi memjym eovimsi
gafm lmtm, eipfapim, jistmklus.
b) Uost J TI Mgeubojs, lijtm hfioj ujtuh loficmt homrmc hiri emj hmjmj
tmjpm lojojkah.
e) Uost jorvus T (Urikolijus)

Dujksi sojsmsi, bmrmjym 0 eojkmj lojkusmp pificmj hmpms pmem hofapmh lmtm mtms emj
gmwmc.
– Wodfohs harjom fmjksujk lmhm kormhmj lojkoeip ipsifmtormf.
– Wodfohs harjom bajsojsumf lmhm kormhmj lojkoeip hajtrmfmtormf.

Usmp pufm eojkmj pificmj hmpms pmem lmxiffm emj lmjeigufm eojkmj lmtm hfioj
tortutup. Porcmtihmj mpmhmc hfioj lormsmhmj memjym sojtucmj
– Dujksi latarih, bmrmjym 0 hfioj eisuruc lojkujymc, polorihsm lofmhuhmj
pmfpmsi pmem atat tolparmf emj lmssotor.
o) Uost jorvus TII (Dmbimfis)
– Dujksi sojsmsi, hm`i sojsmsi rmsm gmkimj mjtoriar fiemc, torcmemp msml, lmjis,
msij pmcit. Hfioj tutup lmtm, usmphmj fmrutmj gormsm eojkmj hmpms/totoshmj,
hfioj tiemh gafoc lojmrih lmsuh fiemcjym hmrojm mhmj lormjksmjk pufm sisi
ymjk socmt.
– Atajal, fmhrilmsi emj smfvims
– Dujksi latarih, hajtraf ohsprosi luhm eojkmjbmrm lolijtm hfioj ujtuh0
torsojyul, lojkoruthmj emci, lojutup lmtm solojtmrm polorihsm gorusmcm
lolguhmjym.
d) Uost jorvus TIII (Mbustihus)

Dujksi sojsaris 0
1) Babcfomr (lojkhm`i pojeojkmrmj), tutup smtu tofijkm hfioj, polorihsm gorgisih
ei smtu tofijkm fmij, mtmu lojkkosohhmj `mri gorkmjtimj hmjmj-hiri.
 7) Tostigufmtar (lojkhm`i hosoilgmjkmj), hfioj eilijtm gor`mfmj furus, mpmhmc
empmt lofmhuhmj mtmu tiemh.
k) Uost jorvus IS (Kfassapcmrijkomf) emj jorvus S (Tmkus)

J IS, lolporsmrmdi pormsmmj lojkobmp pmem 1/2 pastoriar fiemc, tmpi

gmkimj

iji sufit ei tost eolihimj pufm eojkmj L.Rtyfapcmrijkous. Gmkimj pmrmsilpmtih J

IS lolporsmrmdi L. Rmfivmrius ijdoriar. J S, lolporsmrmdi arkmj visormf emj
tcarmbmf, porkormhmj avufm, pmfmtul fujmh, sojsmsi pcmryjx, tajsif emj pmfmtul
fujmh.
c) Uost jorvus SI (Mbbossarius)

Hfioj eisuruc lojafoc hosmlpijk lofmwmj tmcmjmj. Mpmhmc

Rtorjabfoealmstaeous empmt torficmt 1 mpmhmc mtrapi 1 holueimj pmfpmsi
hohumtmjjym. Lijtm hfioj lojkmjkhmt gmcu emj polorihsm gorusmcm lojmcmj tost
atat trmpozius.
i) Jorvus SII (Cypakfasus)
– Lojkhm`i kormhmj fiemc smmt gibmrm emj lojofmj
– Ijspohsi pasisi fiemc (larlmf, msilotris / eovimsi)

Hofumrhmj fiemc hfioj (afoc sojeiri) emj lolmsuhhmj eojkmj bopmt emj lijtm
ujtuh lojkkormhhmj ho hiri emj ho hmjmj.
c. Lojifmi Hohumtmj Atat

Hm`i bmrm gor`mfmj emj hosoilgmjkmj

Agsorvmsi bmrm gor`mfmj, holuemcmj gor`mfmj emj haareijmsi kormhmj tmjkmj, tuguc ‒
hmhi.

Porihsm tajus atat emj hohumtmj

Hohumfmj atat eijymtmhmj eojkmj lojkkujmhmj mjkhm emri >-5

> < tiemh eiempmthmj soeihitpuj hajtrmhsi atat 8 Iulpuc tatmf
1 < torficmt hajtrmhsi totmp 8 tiemh mem kormhmj pmem sojei.
7 < mem kormhmj pmem sojei totmpi tiemh empmt lofmwmj krmvitmsi
2 < gism lofmwmj krmvitmsi totmpi tiemh empmt lojmcmj tmcmjmj polorihsm
5 < gism gorkormh lofmwmj tmcmjmj polorihsm totmpi hohumtmjjym gorhurmjk
5 < empmt lofmwmj tmcmjmj polorihsm eojkmj hohumtmj lmhsilmf
i. Polorihsmmj rodfoh

Polorihsmmj rodfohs gimsmjym eifmhuhmj pmfijk mhcir. Hfioj gimsmjym emfml pasisi

eueuh mtmu tieur `ihm hajeisi hfioj tiemh lolujkhijhmj. Ovmfumsi rospaj hfioj eojkmj
lojkkujmhmj shmfm > ‒ 5
> < tiemh mem
rospaj 1 < Gorhurmjk
(+)
7 < Jarlmf (++)
2 < Fogic emri jarlmf (+++)
5 < Cipormhtid (++++)
1) Wodfoh Disiafakis
m) Wodfoh Uojeaj

– Wodfoh pmtoffm

Pmsioj gogmrijk torfojtmjk futut eimjkhmt homtms dfohsi hurmjk fogic emri 2>>.
tojeaj pmtoffm (eitojkmc-tojkmc pmtofm emj Uugorasitms tigimo) eipuhuf
eojkmj rodfoh cmlor. rospaj gorupm hajtrmhsi atat kumrerisop dolaris ymitu
ohstojsi emri futut.

– Wodfoh Gisop

Fojkmj eidfohsihmj torcmemp sihu eojkmj sueut 9>> supijmsi emj fojkmj gmwmc
eitapmjk mem mtms (lo`m porihsm) `mri porihsm eitolpmt hmj pmem tojeaj
l.gisop (eimtms fipmtmj sihu) holueimj eipuhuf eojkmj rodfoh cmlor.jarlmf `ihm
mem hajtrmhsi atat gibops, soeihit lojijkhmt gifm mem dfohsi sogmkimj mem
prajmsi, cipormhtid lmhm mhmj to`mei pojyogmrmj kormhmj-kormhmj pmem `mri
mtmu sojei.

– Wodfoh trisop

Fojkmj gmwmc eisolidfohsihmj, tojeaj gisop eipuhuf eojkmj eojkmj rodfoh cmlor
(tojeaj gisop gormem pmem `mrmh 1-7 bl eimtms afohrajaj) rospaj ymjk
jarlmf memfmc hajtrmhsi atat trisop, soeihit lojijkhmt gifm mem ohstojsi
rijkmj emj cipormhtid gifm ohstojsi gifm ohstojsi sihu torsogut lojyogmr
homtms smlpmi ho atat ‒ atat gmcu.
– Wodfoh Mbcifos

Pasisi hmhi memfmc earsa dfohsi ujtuh loluemc hmj polorihsmmj rodfoh iji hmhi
 ymjk eiXorihsm eifotmhmj/eisifmjkhmj eimtms tujkhmi gmwmc hajtrmf
fmtormf.tojeaj mbcifos eipuhuf eojkmj rodfoh cmlor, rospaj jarlmf gorupm
kormhmj pfmjtmr dfohsi hmhi.

– Wodfoh Rupordisimf
✓ Wodfoh hufit porut
✓ Wodfoh hrolomstor
✓ Wodfoh harjom
✓ Wodfoh gufgahmvorjasus
✓ Wodfoh pfmjtmr
– Wodfoh Pmtafakis
✓ Gmgijshi

Lorupmhmj rodfoh ymjk pmfijk pojtijk im cmjym ei`ulpmi pmem pojymhit

trmhtus hartihaspitmf.ujtuh lofmhuhmj tos iji, karosfmc humt-humt gmkimj
fmtormf tofmpmh hmhi gmkimj fmtormftofmpmh hmhi emri tulit ho mrmc
`mri hofijkhijk emj holueimj lofijtmsi gmkimj `mjtujk hmhi. Wospaj gmgijshi
tilguf `ihm igu `mri hmhi lofmhuhmj earsadfohsi emj `mri-`mri fmij
lojyogmr,hfmu jarlmfjym memfmc dfohsi pfmjtmr pmem solum `mri hmhi.

Bmrm fmij ujtuh lolgmjkhithmj rmjksmjkmj gmgijshi0

✓ Bmrm bcmeeabh

Wmjksmjk eigorihmj eojkmj `mfmj lojkkaros gmkimj fmtormf lmfoafus cmsif pasitid
gifm kormhmj earsaohstojsi emri igu `mri emj kormhmj mgeuhsi emri `mri`mri
fmijjym.
✓ Bmrm Kareaj

Lolojbot ( lojbugit) atat gotis

✓ Bmrm Appojcoil
✓ Lojkurut eojkmj humt tigim emj atat tigimfis mjtoriar mrmc lojkurut
hogmwmc (eistmf)
✓ Bmrm Kajem

Lolojbot (lojohmj) smtu `mri hmhi emj holueimj lofopmshmjjym sohajyajk

hayajk.
 `. Wmjksmjkmj Lojijkomf

Ujtuh lojkotmcui rmjksmjkmj sofmput atmh (lismfjym pmem lojijkitis)

eifmhuhmj polorihsmmj 0

(1) Hmhu hueuh

Gifm focor ei tohuh sobmrm pmsid torempmt tmcmjmj, socijkkm emku tiemh empmt
lojolpof pmem emem --- Hmhu hueuh pasitid (+)
(7) Umjem Gruezujshy I

Fotmhhmj smtu tmjkmj polorihsm ei gmwmc hopmfm hfioj emj tmjkmj fmij ei emem hfioj
ujtuh lojbokmc gmemj tiemh tormjkhmt.Holueimj hopmfm hfioj ei dfohsihmj hoemem
sobmrm pmsid.Gruezijshy I pasitid (+).
(2) Umjem Gruezijshy II

Umjem gruezijshy II pasitid (+) gifm dfohsi hfioj pmem sojei pmjkkuf sobmrm pmsid
mhmj eiihuti afoc dfohsi tujkhmi fmijjym pmem sojei pmjkkuf emj futut.
(5) Umjem horjiq

Dfohsi tujkhmi mtms tokmh furus,fmfu eibagm lofurushmj tujkhmi gmwmc pmem sojei
futut jarlmf-,gifm tujkhmi lolgojtuh sueut 125> torcmemp tujkhmi mtms. Horjiq +
gifm ohstojsi futut pmsid mhmj lojyogmghmj rmsm smhit togifm ohstojsi futut
pmsid mhmj lojyogmghmj rmsm smhit torcmemp cmlgmtmj.
(5) Uost fmsokuo

Dfohsi sojei pmcm eojkmj sojei futut ymjk furus mhmj lojilgufhmj jyori sopmj`mjk
Lisbcimeibus.
h. Emtm Pojuj`mjk
(1) Fmgarmtariul
✓ Colmtafaki
✓ Hilim hfijih
(7) Wmeiafaki
✓ BU Rbmj0 Lolporficmthmj memjym oeolm , colmtalm, isholim emj memjym ijdmrh

✓ LWI0 Lojuj`uhmj emormc ymjk lojkmfmli ijdmrh, colarmkih.

✓ Rijmr S Uojkharmh0 Lojkkmlgmrhmj porugmcmj hofoj`mr folpojk pijomf
 7. Eimkjasm Hopormwmtmj
m. Wosiha Pordusi sorogrmf tiemh odohtid (E.>>1;)
g. Kmjkkumj Halujihmsi Torgmf (E.>119).
b. Eodisit pormwmtmj eiri (E.>1>9)
e. Kmjkkumj Lagifitms Disih (E.>>55)
o. Gorsicmj @mfmj Jmdms Uiemh Odohtid (E.>>>1)
d. Kmjkkumj Porsopsi Rojsari (E.>>35).
k. Eodisit Jutrisi (E.>>19)
c. Wosiha Boeorm (E.>124)

2. Wojbmjm Msucmj Hopormwmtmj

Eimkjasm
Ja.Hopormwmtmj Uu`umj (RFHI) Ijtorvojsi (RIHI)
(REHI)
1. REHI 0RFHI0PordusiRIHI0Lmjm`olojPojijkhmtmj
Wosiha RorogrmfohspohtmsiUohmjmj Ijtrmhrmjimf (I.>4195)
Pordusi
lojijkhmt (F.>7>15) Agsorvmsi
sorogrmf Rotofmc eifmhuhm 1. Ieojtidihmsipojyogmgpojijkhmtmj
tijemhmj j
tiemhodohtid UIH (lis.Fosi, kmjkkumj
(E.>>1;) hopormwmtmj sofmlm 1 lotmgafislo, oeolm sorogrmf).
x 7.Lajitar tmjem emj ko`mfm pojijkhmtmj

UIH (lis.tohmjmj emrmc lojijkhmt,

7 `ml, lolgmih

eicmrmphmj Pordusi
Rorogrmf
lojijkhmt eojkmj
Hritorim Cmsif 0

1. Uijkhmt
hosmemrmj

lojijkhmt

7. Hakjitid Lojijkhmt

2. Uohmjmj Ijtrm
hrmjimf lojuruj
5. Rmhit
hopmfm

lojuruj

5. Kofismc lojuruj

4. Hobolmsmj

lojuruj

;. Mkitmsi Lojuruj

3. Eolml Lojuruj

9. Jifmi rmtm-

rmtm tohmjmj

emrmc
lolgmih
1>. Uohmjmj

emrmc sistafih
lolgmih
11. Wodfohs

smrmd
 tohmjmj jmei lofogmr, grmeihmreim, pafm jmdms
irokufor, hosmemrmj lojuruj).
2. Lajitar LMP (Lomj Mrtorimf Prossuro)
5. Lajitar BTP (Bojtormf Tojaus Prossuro),
`ihm porfu.
5. Lajitar PM[P (Puflajmry bmpiffmry woeko
prossuro), `ihm porfu
4. Lajitar PMP (puflajmry mrtory prossuro),
`ihm porfu
;. Lajitar IBP (Ijtrm brmjimf prossuro), @ihm
torsoeim)

3. Lajitar BPP (borogrmf Pordusiaj Prossuro)

9. Lajitar kofalgmjk IBP 1>. Lajitar

stmtus porjmdmsmj

11. Lajatar ijtmho emj autput bmirmj

17. Lajitar bmirmj sorogra-spijmfis

(lis.wmrjm, hajsistojsi)
Uormpioutih

1. Lijilmfisir stilufmsi eojkmj

lojyoeimhmj fijkhujkmj ymjk tojmjk
7. Gorihmj pasisi soli dawfor

2. Cijemri lmjouvor vmfsmvm

5. Bokmc tor`meijym ho`mjk

5. Cijemri pojkkujmmj POOP

4. Cijemri pojkkujmmj bmirmj IT cipatajih

;. Mtur vojtifmtar mkmr PmBA7 aptilmf

3. Portmcmjhmj sucu tuguc jarlmf

Hafmgarmsi

1. Hafmgarmsi polgorimj soemsi emj mjti

 hajvufsmj, `ihm porfu
7.Hafmgarmsi polgorimj eiurotib
aslasis, `ihm porfu
2.Hafmgarmsi polgorimj pofujmh tij`m,

`ihm porfu.

7.REHI 0 RFHI0HalujihmsiRIHI 0 Pralasi Halujihmsi 0 eodisit

Kmjkkumj vorgmf Ohspohtmsigibmrm (I.12597)

Komunikasi Membaik
meningkat (L.13117)
Verbal 13. Polmcmlmj Halujihmsi
Rotofmc eifmhuhmj
(D.0119)
tijemhmj
hopormwmtmj sofmlm 2
x

75 `ml,
eicmrmphmj
halujihmsi
vorgmf
lojijkhmt eojkmj
Hritorim cmsif0
1. Holmlpumj
gorgibmrm
Meningkat
2. Holmlpumj
lojeojkmr
Meningkat
3. Hososumimj ohsprosi
wm`mc/tuguc
Meningkat
4. Hajtmh
Lmtm

Meningkat

5. Mdmsim Menurun

6. Eisdmsim Menurun

7. Eismtrim Menurun

8. Mdajim Menurun

9. Eisfmfim Menurun

10. Pofa Menurun

11. Kmkmp Menurun

12. Wospajs porifmhu

Observasi (lis.goreiri ei s 1>. Kujmhmj `uru gibmrm, `ihm
eopmj
1. Lajitar porfu
pmsioj,
eojkmrhmj
Hobopmtmj,
eojkmj
sohsmlm,
tohmjmj, humjtitms,
tuj`uhmj smtu
vafulo emj eihsi
kmkmsmj
gibmrm
mtmu
7. Lajitar prasos hakjitid,
mjmtalis emj polihirmj

disiafakis ymjk sohmfikus,

gibmrm
gorhmitmj eojkmj
eojkmj
gibmrm (lis.lolari,
pojeojkmrmj emj porfmcmj

gmcmsm) smlgif

2. Lajitar drustrmsi, lojkcijemri

lmrmc, eodrosi torimhmj,

mtmu cmf fmij ymjk kujmhmj

lojkkmjkku gibmrm halujihmsi

5. Ieojtidihmsi tortufis,
mtmu lolijtm

porifmhu gmjtumj
hofurkmujtuh

olasiajmf emj lolmcmli

disih sogmkmi ubmpmj

gojtuh halujihmsi pmsioj)

Terapeutik ;. Laeidihmsi
fijkhujkmj
5. Kujmhmj lotaeohalujihmsi ujtuh
mftorjmtid
(lis.lojufis, lmtm lolijilmfhmj
gorhoeip, pmpmj gmjtumj
halujihmsieojkmj 3. Ufmjki mpm ymjk
eismlpmihmj pmsioj
kmlgmr emj curud,
isymrmt tmjkmj emj 9. Gorih
balputor)
mj
4. Rosumihmj kmym
euhujkmj
halujihmsi eojkmj
hogutucmj psihafaki
Membaik
 Oeukasi

11. Mj`urhmj polgibmrmmj porfmcmj

17. M`mrhmj pmsioj emj hofumrkm prasos

hakjitid, mjmtalis emj disiafakis ymjk
gorcugujkmj eojkmj holmlpumj
gorgibmrm
Kolaborasi

5. Torgmfismsi

hoijkijmj
2. RDKI 0 RLKI 0 Perawatan eiri

Dedisit eengan Okspektasi

perawatan meningkat (L.13121)

eiri (D.0109) Rotofmc eifmhuhmj

tijemhmj hopormwmtmj
sofmlm 2 x 75 `ml,
eicmrmphmj Pormwmtmj
eiri lojijkhmt eojkmj

Hritorim Cmsif 0

1. Holmlpumj lmjei

Meningkat

2. Holmlpumj
Lojkojmhmj
pmhmimj
Meningkat
3. Holmlpumj lmhmj
Lojijkhmt
4. Holmlpumj
ho taifot
(GMG/GMH)
meningkat
12. Wu`uh ho mcfi pmtafaki homemmj
gibmrm mtmu
hotorkmjtujkmj
tormpis.
3. Dmsifitmsi
RIKI 0 Dukungan
perawatan eiri (I.11348)
holmjeirimmj
Observasi 0 ,
gmjtu
1. Ieojtidihmsi `ihm tiemh
hogimsmmj mhtivitms lmlpu
pormwmtmj eiri lofmhuhmj
sosumi usim pormwmtmj
7. Lajitar tijkhmt holmjeirimmj

2. Ieojtidihmsi hogutucmj
mfmt gmjtu
hogorsicmj eiri,
gorpmhmimj,
gorcims emj lmhmj
Terapeutik

5. Roeimhmj fijkhujkmj
ymjk tormpoutih
(lis.sumsmjm
cmjkmt,rifohs,privm
si)
5. Rimphmj

hoporfumj

prigmei (lis.pmrdul,
sihmt kiki emj smguj
lmjei)
4. Emlpijki

emfml

lofmhuhmj
pormwmtmj eiri
smlpmi lmjeiri
;. Dmsifitmsi ujtuh lojorilm
 lofmhuhmj
6. Hmhu Rojei
pormwmtmj eiri
Meningkat Menurun

6. Lolportmcmjhmj
hogorsicmj eiri
Meningkat
7. Lolportmcmjhmj
hogorsicmj lufut
Meningkat
5. RDKI 0 RLKI0 Mobilitas disik

Kangguan Okspektasi meningkat

Mobilitas (L.05042)

Disik
Rotofmc eifmhuhmj
(D.0054)
tijemhmj

pormwmtmj sofmlm 2 x 75
`ml, eicmrmphmj
Lagifitms disih lojijkhmt
eojkmj

Hritorim cmsif 0

1. Porkormhmj
ohstrolitms
Meningkat
2. Hohumtmj atat

Meningkat

3. Wojtmjk
kormh (WAL)
Meningkat
4. Jyori Menurun

5. Hobolmsmj

Menurun
 eiri 4. Dmsifitmsi
lofmhuhmj
9. @mewmfhmj
rutijitmspormwmtmj eiri porkormhmj,
`hm porfu
Oeukasi
;. Figmthmj
1>. Mj`urhmj
hofumrkm
lofmhuhmj
ujtuh lolgmjtu
pormwmtmj eiri
pmsioj
sobmrm
hajsistoj sosumi
emfml
holmlpumj

lojijkhmthmj
porkormhmj
Oeukasi
RIKI 0 Dukungan
3. @ofmshmj
mobilisasi
tu`umj emj
(I.05173) Observasi
prasoeur
1. Ieojtidihmsi memjym jyori
mtmu hofucmj lagifismsi
disih fmijjym

7. Ieojtidihmsi
taformjsi disih
lofmhuhmj
porkormhmj
2. Lajitar drohuojsi
`mjtujk emj
tohmjmj emrmc
sogoful lolufmi
lagifismsi
5. Lajitar Hajeisi ulul
sofmlm
lofmhuhmj
lagifismsi
Terapeutik

5. Dmsifitmsi
mhtivitms
lagifismsi eojkmj
mfmt gmjtu
(lis.Pmkmr
tolpmt tieur)
7.Kormhmj tiemh
 torhaareijmsi 9. Mj`urhmj lagifismsi eiji

Menurun 1>. M`mrhmj lagifismsi soeorcmjm ymjk

8. Kormhmj cmrus eifmhuhmj (lis.eueuh eitolpmt

torgmtms tieur, eueuh eisisi tolpmt tieur,

Menurun pijemc emri tolpmt tieur ho hursi)

9. Hofolmcmj
disih
RIKI 0 Managemen `alan nadas
Menurun
5. RDKI 0 RLKI0 Gersican `alan
Gersican
nadas Okspektasi
@alan Jadas menurun
meningkat (L.01001)
Tieak 7. Rimjasis Menurun
Odektid
Rotofmc eifmhuhmj
(D.0001) 8. Kofismc Menurun
tijemhmj

pormwmtmj sofmlm 2 x 75
`ml, eicmrmphmj
gorsicmj
`mfmj jmdms lojijkhmt
eojkmj 0
Hritorim Cmsif 0

1. Gmtuh
odohtid

Meningkat

2. Praeuhsi sputul
Menurun

3. [coozijk Menurun

4. Eispjom Menurun

5. Artapjom Menurun

6. Rufit
gibmrm
(I.01011)

Observasi

l. Lajitar pafm jmdms

2. Lajitar gujyi jmdms

3. Lajitar sputul
Terapeutik
4. Portmcmjhmj hopmtojmj
`mfmj jmdms
5. Pasisihmj soli dawfor
mtmu dawfor
6. Gorihmj lijul cmjkmt
7. Fmhuhmj disiatormpi
emem,
jika perlu
8. Fmhuhmj
pojkcismp
mj fojeir
hurmjk
emri 15
eotih
9. Gorihmj ahsikoj, `ihm
porfu
Oeukasi
lO. M`mrhmj tohjih gmtuh
odohtid
Kolaborasi
ll. Hafmgarmsipolgorimj
grajhaeifmtar,ohs
pohtarmj,luhafi
tih,jika perlu
 9.Drohuojsi jmdms

Membaik

10. Pafm jmdms

4. RDKI 0 Membaik RLKI0 RIKI 0 Minimalisasi rangsangan
Persepsi sensori
Kangguan (I.08241)
Okspektasi membaik
 Persepsi (L.09083) Observasi
Rensori
Rotofmc eifmhuhmj 1. Porihsm stmtus lojtmf, stmtus
(D.0085)
tijemhmj pormwmtmj sojsari, emj tijkhmt hojymlmjmj
sofmlm 2 x 75 `ml, Terapeutik

eicmrmphmj Porsopsi 7. Eishusihmj tijkhmt taformjsi

torcmemp gogmj sojsari
sojsari lolgmih
2. Gmtmsi stilufus fijkhujkmj
eojkmj0
5. @mewmfhmj mhtivitms
Hritorim Cmsif 0
cmrimj emj wmhtu istirmcmt
1. Eistarsi sojsari
5. Halgijmsihmj prasoeur/tijemhmj
Menurun emfml smtu wmhtu, sosumi
hogutucmj
Oeukasi
2. Lojmrih eiri
4. M`mrhmj bmrm lolijilmfismsi
Lojuruj
stilufus
3. Lofmluj Menurun
Kolaborasi
4. Hajsojtrmsi ;. Hafmgarmsi emfml lolijilmfhmj
prasoeur/tijemhmj
Membaik
3. Hafmgarmsi polgorimj agmt ymjk
lolpojkmruci porsopsi stilufus

;. RDKI 0 RLKI0 Rtatus nutrisi RIKI 0 Managemen nutrisi (I.08119)

Dedisit
membaik (L.03033) eicmgishmj
Jutrisi
(D.0019) Retelac eilakukan
tineakan perawatan
selama 3 x 24 `am,
eicarapkan status
nutrisi membaik
eengan0

Kriteria Casil 0

1. Parsi lmhmjmj ymjk

Observasi

l. Ieojtidihmsi stmtus
jutrisi
2. Ieojtidihm
si mforki
emj
ijtaformjsi
lmhmjmj
3. Ieojtidihmsi lmhmjmj
ymjk eisuhmi
4. Ieojtidihmsi
hogutucmj hmfari
emj
`ojis jutrioj

5. Ieojtidihms
i porfujym
pojkkujmm
j sofmjk
nasogastrik
6. Lajitar msupmj
lmhmjmj
7. Lajitar gormt gmemj
 Meningkat 8. Lajitar cmsif polorihsmmj
2. Pormsmmj fmgarmtariul
bopmt hojymjk Terapeutik
Menurun 9. Fmhuhmj oral hygiene sogoful
3. Jyori mgealoj lmhmj
lO. Rm`ihmj lmhmjmj sobmrm lojmrih
emj sucu ymjk sosumi
ll. Gorihmj lmhmjmj tijkki sormt
 Menurun ujtuh lojbokmc hajstipmsi

4. Gormt gmem l2. Gorihmj lmhmjmj tijkki hmfari emj

j tijkki pratoij
Membaik
lmhm Oeukasi
5. Jmdsu j l3. Mj`urhmj pasisi eueuh

Membaik lmhm jika mampu

j l4. M`mrhmj eiot ymjk eiprakrmlhmj
6. Drohuojsi
Kolaborasi
Membaik l5. Hafmgarmsi polgorimj loeihmsi
sogoful lmhmj
l6. Hafmgarmsi eojkmj mcfi kizi ujtuh
lojojtuhmj `ulfmc hmfari emj
`ojis jutrioj ymjk eigutuchmj
3.
RDKI 0 RLKI0 Tingkat beeera RIKI 0 penbegacan bieera (I.14537)
Wesi menurun (L.14136)
Observasi
Beeera
(D.0136) Rotofmc eifmhuhmj
1. Ieojtidihmsi mrom fijkhujkmj
tijemhmj pormwmtmj
ymjk gorpatojsi lojyogmghmj
sofmlm 2 x 75 `ml,
boeorm
tijkhmt boeorm lojuruj
Terapeutik
eojkmj0
7. Roeimhmj pojbmcmymmj

Hritorim Cmsif 0 ymjk lolmemi

2. Rasimfismsihmj pmsioj emj hofumrkm

1. Uaformjsi Mhtivitms eojkmj fijkhujkmj rumjk rmwmt

5. Roeimhmj pispat mtmu urijmf
Meningkat
ujtuh ofilijmsi ei tolpmt tieur,`ihm
2. Jmdsu lmhmj porfu

Meningkat 5. Pmstihmj gof pmjkkifmj

mtmu tofopaj luemc
3. Uaformjsi lmhmjmj
ei`mjkhmu
Meningkat 4. Pmstihmj gmrmjk-gmrmjk

4. Ho`meimj prigmei luemc ei`mjkhmu

boeorm ;. Kujmhmj pojkmlmj tolpmt tieur

Menurun sosumi eojkmj hogi`mhmj

 dmsifitms
pofmymjm
j
hosocmtm
j
3. Eishusihmj
gorsmlm
mjkkatm
hofumrkm
ymjk
empmt
lojemlpijki
5. Fuhm/fobot Menurun pmsioj

6. Ohsprosi 9. Uijkhmthmj drohuojsi agsorvmsi

wm`mc hosmhitmj emj pojkmwmsmj pmsioj,
Menurun sosumi hogutucmj
7. Kmjkkumj lagifitms Edukasi

Menurun 1>. @ofmshmj mfmsmj ijtorvojsi

pojbokmcmj `mtuc ho pmsioj emj
8. Uohmjmj
emrmc hofumrkm
Kolaborasi
11. Mj`urhmj gorkmjti pasisi sobmrm
 Membaik porfmcmjemjeueuhsofmlm
gogormpm lojit sogoful goreiri
9. Drohuojsi jmei

Membaik
10.

Pafm istirmcmt/tieur

Membaik
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