askeppneumotoraks

7/25/2019 askeppneumotoraks

1/20

ASUHAN KEPERAWATAN KLIEN TN.S DENGAN

PNEUMOTORAKS DEXTRA

DI RUANG DAHLIA RSUD ULIN BANJARMASIN

A. Identitas Pasien : nama , umur, alamat, !t.....t"l MRS, tgl pengkajian,

#.m$%!.......

B. Riwayat Penyakit

&. K$lu'an utama

S$!a( na)a!, *$rna)a! t$ra!a *$rat an !u!a' untu( m$la(u(an

)$rna)a!an.+. R%a-at )$n-a(%t !$(aran"

T%"a am -an" lalu (l%$n m$naa( m$n"$lu' !$!a( na)a! an !$ma(%n

lama !$ma(%n *$rat, %!$rta% n-$r% aa !$)$rt% t$rtu!u( )aa !%!% aa

!$*$la' (anan, ra!a *$rat, t$rt$(an an t$ra!a l$*%' n-$r% )aa "$ra(an

)$rna)a!an. T%a( aa r%a-at trauma -an" m$n"$na% r/n""a aa !$)$rt%

t$rt$m*u! )$luru, l$a(an, trauma tum)ul aa a(%*at ($0$la(aan lalu

l%nta! mau)un tu!u(an *$na taam lan"!un" m$n$m*u! )l$ura. Kar$na

($lu'an !$!a( na)a! %ra!a(an !$ma(%n *$rat, (l%$n %*aa ($luar"a ($

IRD RSUD Ul%n Banarma!%n, %!aran(an raat %na) untu( %la(u(ant%na(an )$ma!an"an !$lan" WSD. Kl%$n ma!u( Ruan" Da'l%a )aa am

12.11 W%ta.

3. R%a-at )$n-a(%t a'ulu

S$ta'un -an" lalu (l%$n )$rna' m$n$r%ta )$n-a(%t TB Paru, !ua'

m$nalan% )$n"/*atan OAT !$lama $nam *ulan

4. R%a-at )$n-a(%t ($luar"a

T%a( aa an""/ta ($luar"a -an" m$n$r%ta )$n-a(%t -an" !ama $n"an

(l%$n *a%( )n$um/t/ra(! atau)un TB )aru

5. R%a-at ($*%a!aan !$'ar%6'ar%

S$'ar%6'ar%n-a (l%$n *$($ra !$*a"a% tu(an" (a-u7m$m*uat ruma'. Kl%$n

u"a !$/ran" )$r/(/(, m$n"'a*%!(an m%n%mal !atu *un"(u! r/(/(

(r$t$(7'ar%

C. Pemeriksaan Fisik

K$aaan umum

Tam)a( !a(%t *$rat an !$!a( na)a!, KU !an"at l$ma', ($!aaran 8/m)/!

M$nt%!, G8S 459, TB &55 0m, BB 51 (".


2/20

TT : TD &&17;1 mmH", RR 3+ #7mnt, N 2+ #7mnt, T 39 8

Daa an )$rna)a!an

*. In!)$(!%

Kl%$n tam)a( !$!a( na)a!, ($r%n"at %n"%n, aa' tam)a( )u0at, n-$r% aa

!aat *$rna)a! an "$l%!a'

B$ntu( aa (anan l$*%' 0$m*un"

G$ra(an )$rna)a!an aa (anan t$rt%n""al

P$n""unaan /t/t *antu na)a! tam*a'an

P/la na)a! 0$)at an an"(al

0. Pal)a!%

Ta(t%l /t/ t'/ra(! AP6Lat tan""al &2646+1&& : uun" !$lan" % I8 465

>/t/ t'/ra(! AP6Lat tan""al ++646+1&& : uun" !$lan" % I8 465. ta(

tam)a( )n$um/t/ra(!, )aru $(!)an!%

F.

Pengobatan


3/20

I>D RL +1 t)m

R%m!tar + # + ta*

8/$%n &1 m" ta* 16&6&

H$)a @ + # & ta*

O(!%"$n + l)m

Ran%t%%n + # & am) I

Trama/l + # & m" r%)

8$


4/20

& DS:

Kl%$n m$n"$lu'!$!a( na)a!,

*$rna)a! t$ra!a

*$rat, !u!a'

untu( m$la(u(an

)$rna)a!an an

n-$r% aa (anan

!aat *$rna)a!

DO:

Kl%$n tam)a(!$!a( na)a!,

($r%n"at %n"%n,

n-$r% aa (anan

!aat *$rna)a! an

"$l%!a'

B$ntu( aa

(anan l$*%'

0$m*un"

G$ra(an

)$rna)a!an aa

(anan t$rt%n""al

P$n""unaan /t/t

*antu na)a!

tam*a'an

P/la na)a! 0$)at

an an"(al

TT : TD &&17;1

mmH", RR 3+

#7mnt, N 2+

#7mnt, T 39 8

Pal)a!%:"$taran

m$nurun % aa

(anan

P$r(u!%:

'%)$r!/n/r %

P$nurunan

$(!)an!% )aru

!$(un$r

t$r'aa)

)$n%n"(atan

t$(anan %

alam r/n""a

)l$ura

)n$um/t'/ra#

P/la na)a!

t%a( $


5/20

aa (anan

Au!(ulta!%: !uarana)a!

m$n"'%lan" %

aa (anan

Ra%/l/"%:


6/20

0m $n"an

a'%tan

m$n"$l%l%n"%

!$lan" WSD

T$r)a!an" !$lan"

WSD % I8 465

%'u*un"(an

$n"an !$lan"

)$n-am*un" ($

*/t/l WSD

K. Prioritas $asalah

a. P/la na)a! t%a( $


7/20

!aat *$rna)a!

DO:

Kl%$n tam)a( !$!a(

na)a!, ($r%n"at %n"%n,

n-$r% aa (anan !aat

*$rna)a! an "$l%!a'

B$ntu( aa (anan

l$*%' 0$m*un"

G$ra(an )$rna)a!an

aa (anan t$rt%n""al

P$n""unaan /t/t *antu

na)a! tam*a'an

P/la na)a! 0$)at an

an"(al

TT : TD &&17;1

mmH", RR 3+ #7mnt, N

2+ #7mnt, T 39 8

Pal)a!%:"$taranm$nurun %!%!% )aru

-an" !a(%t

P$r(u!%: '%)$r!/n/r

%!%!% )aru -an" !a(%t

Au!(ulta!%: !uara na)a!

m$n"'%lan" %!%!% )aru

-an" !a(%t

Ra%/l/"%:


8/20

&&.11 !$(un$r )$ma!an"an

!$lan" WSD %tana%

$n"an:

DS:

P# m$n"ata(an

t$r)a!an" !$lan" %aa

(anan

DO:

Aan-a lu(a & 0m

$n"an a'%tan

m$n"$l%l%n"% !$lan"

WSD

T$r)a!an" !$lan" WSD

% I8 364 %'u*un"(an

$n"an !$lan"

)$n-am*un" ($ */t/l

WSD

%nt$r$n!% r%!t%

%n


9/20

($alaman na)a!, la)/r(an !$t%a)

)$ru*a'an -an" t$ra%

3. M$m*ar%n"(an (l%$n alam )/!%!%

-an" n-aman, atau alam )/!%!%

uu(

4. M$n"u(ur TT t%a)..... am

5. M$la(u(an IPPA t%a) ..... am

9. M$m*$r%(an /(!%"$n tam*a'an

na!al (anul$ + l)m

;. A!%!t$n!% alam )$la(!anaan

t%na(an $(/m)r$!% )$ma!an"an

!$lan" WSD C)$r!%a)an alat,

)a!%$n, ruan" t%na(an, m$m*antu

)$la(!anaan an $alua!% )/!t

)$ma!an"an WSD

- S$n%n

&?646

&&

&&.11

I &. M$n"(a% (ual%ta!,


10/20

!$lan" alam */t/l WSD a"ar

!$lalu *$raa + 0m %*aa' a%r

. M$m*$r!%'(an70u0% */t/l *%la

t$rl%'at (/t/r

?. M$m*$r%(an /*at ant%*%/t%(a an

OAT !$!ua% )r/"ram:

In 8$


11/20

aa (anan !aat *$rna)a!

T%a( m$n""una(an /t/t *antuna)a! tam*a'an

T%a( m$n""una(an /(!%"$n

tam*a'an

P/la na)a! mula% t$ratur

TT : TD &&17;1 mmH", RR

+? #7mnt, N ?? #7mnt, T 39 8

Pal)a!%: t$ra*a "$taran %!%!%

)aru (anan

P$r(u!%: '%)$r!/n/r %)aru

(anan !ua' *$r(uran"

Au!(ulta!%: !ua' t$r$n"ar

!uara na)a! % )aru (anan

Kl%$n tam)a( l$*%' t$nan"7r%l$(!

A0 Ma!ala')/la na)a! t%a(

$


12/20

T%a( aa (r$)%ta!% %!$(%tar

!$lan"

Unula!% )/!%t%


13/20

Tam)a( "$l$m*un" uara

($luar m$lalu% uun" !$lan"

%alam */t/l WSD !aat *atu(

K$0$m*un"an aa (anan mula%

*$r(uran"

Sua' mula% t$rl%'at )$r"$ra(an

aa (anan !aat *$rna)a!

P/la na)a! mula% t$ratur

TT : TD &+17;1 mmH", RR

+4 #7mnt, N ?4 #7mnt, T 39 8


)aru (anan

P$r(u!%: '%)$r!/n/r %)aru

(anan !ua' *$r(uran"

Au!(ulta!%: !ua' t$r$n"ar

!uara na)a! % )aru (anan

T$r)a!an" !u0t%/n 0/nt%n/u!

$n"an t$(anan +1mmH"

>/t/ t'/ra(!: uun" !$lan" % I8

465 (anan

A0 Ma!ala' )/la na)a! t%a(

$


14/20

T%a( aa )u! %alam !$lan"

T%a( aa (r$)%ta!% %!$(%tar!$lan"

Unula!% )/!%t%


15/20

B$ntu( aa !%m$tr%!

P$r"$ra(an aa !%m$tr%! !aat*$rna)a!


)aru (anan

P$r(u!%: !/n/r %)aru (anan

Au!(ulta!%: t$r$n"ar !uara

na)a! % )aru (anan

A0 Ma!ala' )/la na)a! t%a(

$


16/20

tam)a( !$!a( na)a!

TT : TD &+17;1 mmH", RR++ #7mnt, N ?4 #7mnt, T 39 8

T$r)a!an" !$lan" WSD % I8 46

5 m%l%n$ a#%la (anan

%!am*un" $n"an !$lan"

)$n"'u*un" ($ */t/l WSD

T$r)a!an" !u0t%/n 0/nt%n/u!

$n"an t$(anan +1

mmH"

Unula!% )/!%t%


17/20

++646&&

12.11

!$lan" %aa (anan

10 T%a( aa trauma )$rna)a!an

an tana6tana %n/t/ t'/ra(!: )aru -an" (/la)!


18/20

m$n"$m*an"

A0Ma!ala'

)/la na)a! t%a(

$


19/20

)u!($!ma!7RS

Anur(an (/ntr/l ($)u!($!ma!7RS *%la aa ($lu'an

,, M%n""u

+4646&&

1?.31

I /0

Kl%$n m$n"ata(an t%a( aa

($lu'an !$!a( na)a!

10

Kl%$n t$rl%'at t$nan"7r%l$(!, ta(

tam)a( !$!a( na)a!

TT : TD &+17;1 mmH", RR

+1 #7mnt, N ?1 #7mnt, T 39 8

B$ntu( aa !%m$tr%!

P$r"$ra(an aa !%m$tr%! !aat

*$rna)a!


)aru (anan

P$r(u!%: !/n/r %)aru (anan

Au!(ulta!%: t$r$n"ar !uara

na)a! % )aru (anan

WSD !ua' % /


20/20

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