intervensi stroke baru

8/12/2019 Intervensi Stroke Baru

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C. INTERVENSI

NO DIAGNOSA TUJUAN DAN KRITERIA

HASIL

INTERVENSI RASIONAL

1. Perubahan perfus!arn"an serebra#

berhubun"an $en"an

n%erups a#ran $arah&

"an""uan '(#usf&

he)'ra"& *as'spas)e

serebra#& e$e)a serebra#

$%an$a $en"an

DS+

, Pasen )en"a%a(an

pusn"&

, Pasen )en"a%a(an

(epa#an-a %erasa

sa(%& n-er $ ba"an

(epa#a $en"an s(a#a

n-er ,/ $ar 0,10

s(a#a n-er -an"$ber(an& n-er

seper% %er%e(an

ben$a bera%.

DO+

, Tan$a,%an$a *%a#

Se%e#ah $#a(u(an asuhan(eperaa%an $harap(an

perfus !arn"an serebra# $apa%

%er2apa se2ara 'p%)a# $en"an

2r%era has# +

1. K#en %$a( "e#sah

3. T$a( a$a (e#uhan

n-er (epa#a& )ua#& $an

(e!an"

4. GCS 5&6&75. Tan$a,%an$a *%a#

n'r)a# 8na$ 70,

1009:)n%& RR17,

309:)n%;


2/16

Te(anan Darah

=130:>0& Na$ =

1009:)en%& RR

=359:)en%& Pasen

%a)pa( )ern"s&

GCS 4&4&1&

-an" %erba2a pa$a (e$ua

#en"an

, ?re(uens $an ra)a

!an%un"& ser%a aus(u#%as

a$an-a )ur)ur

, Ca%a% p'#a $an ra)a

pernafasan

Hper%ens a%au hp'%ens

p's%ura# $apa% )en!a$

fa2%'r pen2e%us. Hp'%ens

$apa% %er!a$ (arena s-'(

8('#aps sr(u#as *as(u#er;.

Penn"(a%an TIK $apa%

%er!a$ 8(arena '$e)a&

a$an-a f'r)as be(uan

$arah;. Tersu)ba%n-a ar%er

sub(#a*a $apa% $n-a%a(an

$en"an a$an-a perbe$aan

%e(anan $arah pa$a (e$ua

#en"an.

, Perubahan %eru%a)a a$an-a

bra$(ar$ $apa% %er!a$

seba"a a(ba% a$an-a

(erusa(an '%a(. Dsr%)a

$an )ur)ur )un"(n

)en2er)n(an a$an-a

pen-a(% !an%un" -an"

)en!a$ pen2e%us s%'(e.

, Ke%$a(%era%uranpernafasan $apa%

)e)ber(an "a)baran

#'(as (erusa(an serebra#

a%au penn"(a%an TIK $an

(ebu%uhan un%u( n%er*ens

se#an!u%n-a %er)asu(

(e)un"(naan per#un-a


3/16

5. Le%a((an (epa#a $en"an p'ss

a"a( $%n""(an $an

$a#a)p'ss ana%')s 8ne%ra#;.

6. Per%ahan(an (ea$aan %rah

barn"& 2p%a(an #n"(un"an

-an" %enan"& ba%as

pen"un!un":a(%*%as pasen

sesua n$(as. @er(an

s%raha% se2ara per'$2 an%ara

a(%*%as peraa%an& ba%as

#a)an-a se%ap pr'se$ur.

7. Ce"ah %er!a$n-a )en"e!an saa%

$efe(as& $an pernafasan -an"

)e)a(sa 8ba%u( %erus,

)enerus;.

. Ka! r"$%as nu(a#& (e$u%an&

(e"e#sahan -an" )enn"(a%&

pe(a ran"san" $an seran"an

(e!an".

K'#ab'ras+

>. Da#a) pe)beran

an%('a"u#as& seper% na%ru)

arfarn 8C'u)a$n;&

an%%r')b's% 8ASA;&

$pr$a)'# 8Persan%ne;.

$u(un"an un%u(pernafasan.

5.


4/16

/. Pe)beran An%fbr'#%(&

seper% asa) a)n'(apr'$

8A)2ar;

10. Pe)beran an%hper%ens

11. Pe)beran *as'$#a%as perfer&

seper% s(#an$e#a%

8C-2#'spas)'#;& papa*ern

8pa*ab$:*as'span;&

s'(supresn 8Vas'$#an;

e)b'#us:%hr')bus )erupa(an

fa2%'r e%'#'"n-a.

/. Pen""unaan $en"an ha%,ha%

$a#a) per$arahan un%u(

)en2e"ah #ss be(uan -an"

%erben%u( $an per$arahan

beru#an" serupa

10. Hper%ens #a)a:(r'ns

)e)er#u(an penan"anan -an"

ha%,ha%& sebab penan"anan

-an" ber#ebhan )enn"(a%(an

res(' %er!a$n-a per#uasan

(erusa(an !arn"an. Hper%ens

se)en%ara sern" (a# %er!a$

se#a) fase s%r'(e a(u% $an

penan"u#an"ann-a sern" (a#

%anpa n%er*ens %erapeu%(.

11. D"una(an un%u( )e)perba(

sr(u#as ('#a%era# a%au

)enurun(an *as'spas)e

3. Kerusa(an )'b#%as fs(

berhubun"an $en"an

(erusa(an fun"s

neur'#'"s& he)p#e"2

Se%e#ah $#a(u(an asuhan

(eperaa%an $harap(an

)'b#%as fs( )en"a#a)

penn"(a%an $en"an 2r%era

has# +

1. K#en %$a( )en"a#a)


5/16

$%an$a $en"an+

DS+

-Pasen )en"a%a(an

su#% )en""era((an

ba$ann-a

- Pasen )en"a%a(an

%$a( )a)pu

)e#a(u(an

a(%*%asn-a

DO+

- Pasen %a)pa( %$a(

)a)pu bera(%*%as

- Ta)pa( (e#e)ahan

pa$a e(s%re)%as

-A(%*%as pasen

%a)pa( $ban%u '#eh

(e#uar"an-a

- Ke(ua%an '%'%

)enurun

('n%ra(%ur '%'% a(%f $an pasf pa$a se)ua

e(s%er)%as se2ara ber%ahap.

An!ur(an )e#a(u(an #a%han

seper% )ere)as b'#a (are%&

)e#ebar(an !ar,!ar $an (a(

a%au %e#apa(.

4. Te)pa%(an ban%a# $baah

a(s#a un%u( )e#a(u(an

ab$u(s pa$a %an"an.

5. @an%u %n""(an %an"an pasen.

6. Te)pa%(an har$ r'##B (eras

pa$a %e#apa( %an"an $en"an bu

!ar $an !ar,!ar sa#n"

berha$apan.

7. P'ss(an #u%u% $an pan""u#

$a#a) p'ss e(s%ens.

. Per%ahan(an (a( pa$a p'ss

ne%ra# $en"an "u#un"an a%au

ban%a#an %r'(an%er.

>. Guna(an papan (a( se2ara

ber"an%& !(a )e)un"(n(an.

/. @an%u un%u( )en"e)ban"(an(ese)ban"an $u$u( $an

(ese)ban"an $a#a) ber$r.

10. Obser*as $aerah -an" %er(ena

%er)asu( arna& '$e)a& a%au

%an$a #an $ar "an""uan

sr(u#as.

11. @an"un(an $ar (urs sese"era

$a#a) pe)#han %erha$ap

n%er*ens.

3. . Pen""unaan -an" 2'n%nu

$apa% )en-ebab(an %e(anan

-an" ber#ebhan pa$a sen$

pe#uru (a(& )enn"(a%(an

spas%s%as& $an se2ara n-a%a

)enn"(a%(an f#e(s p#an%ar.


6/16

)un"(n se%e#ah %an$a,%an$a

*%a# s%ab# (e2ua# pa$a

he)'ra"( serebra#.

13. A#as (urs $u$u( $en"an busa

a%au ba#'n ar $an ban%u pasen

un%u( )e)n$ah(an bera%

ba$an $en"an n%er*a# -an"

%era%ur.

14. A!ar(an (e#uar"a a%au 'ran"

%er$e(a% $a#a) a(%*%as:#a%han

$an )en"ubah p'ss

15. An!ur(an pasen un%u(

)e)ban%u per"era(an $an

#a%han $en"an )en""una(an

e(s%er)%as -an" %$a( sa(%

un%u(

)en-'('n":)en""era((an

ba"an %ubuh -an" )en"a#a)

(e#e)ahan.

K'#ab'ras

16. K'nsu#%as(an $en"an ah#

fs'%erap se2ara a(%f& #a%han

ress%f& $an a)bu#as pasen.

17. @an%u )en""una(an s%)u#as

e#e(%r(& seper% TENS sesua

n$(as.

1. @er(an 'ba% re#a(san '%'%&

an%spas)'$2 sesua n$(as

/.


7/16

8ba(#'fen& $a%r'#en;. 17. Dapa% )e)ban%u )e)u#h(an

(e(ua%an '%'% $an

)enn"(a%(an 2'n%r'# '%'%

*'#un%eer.

1. Dper#u(an un%u(

)en"h#an"(an spas%s%as pa$a

e(s%er)%as -an" %er"an""u.

4. Res(' %n"" %erha$ap

2e$era berhubun"an

$en"an $efs% #apan"

pan$an" )'%'r( a%au

perseps $an (e#e)ahan

fs(


(eperaa%an $harap(an %$a(

%er!a$ 2e$era $en"an 2r%era

has# +

1. T$a( %er!a$ 2e$era

3. T$a( %er$apa% #u(a

1. Pasan" pa"ar %e)pa% %$ur

3. Guna(an 2aha-a -an"

2u(up

1. Pa"ar %e)pa% %$ur

)e#n$un" (#en a"ar %$a(

%er!a%uh $ar %e)pa% %$ur

3. Gan""uan *sua#

)enn"(a%(an res('

%rau)a pa$a (#en

5. N-er a(u% behubun"an

$en"an penn"(a%an TIK

$%an$a $en"an

DS+

- pasen )en"a%a(an

n-er $ $aerah(epa#an-a& n-er

$rasa(an seper%

%er%e(an ben$a bera%&

s(a# n-er bera% ,/

$ar 10 s(a#a n-er

-an" $ber(an.


(eperaa%an $harap(an n-er

ber(uran" $en"an 2r%era has#

+

1. N-er h#an" a%au

ber(uran" saa%

bera(%*%as.3. S(a#a n-er 0 $ar 0,10

s(a#a n-er -an" $ber(an

4. a!ah pasen %a)pa(

%enan"

5. Tan$a,%an$a V%a# (e)ba#

n'r)a#+

TD + 100,130 : 70,>0


8/16

DO+

-pasen %a)pa(

)e)e"an"

$aerah (epa#an-a&

pasen %a)pa(

)ern"s&

- %an$a,%an$a *%a#

pasen $a%as

n'r)a# 8TD+ =

130:>0))H"&

Na$ =

1009:)en%& RR =

359:)n%& S = 4&6

C;

))H"

N + 70,100 (a#:)en%

S + 47&6 4&5 C

RR + 17 35 9:)en%

6. An!ur(an %e(n( $s%ra(s $an

re#a(sas

K'#ab'ras+

7. @er(an 'ba% ana#"e%( sesua

$en"an pr'"ra) %erap.

6. Ds%ra(s $an re#a(sas& $apa%

)en"uran" rasa n-er pasen

7. Ana#"e%( )e)ban%u

)en"uran" rasa n-er

6. Perubahan nu%rs (uran"

$ar (ebu%uhan %ubuh


(eperaa%an $harap(an nu%rs

1. Sebe#u) )e)ber(an

)a(an& (a! apa(ah pasen

1.


9/16

berhubun"an $en"an

(e%$a()a)puan

)ene#an se(un$er

%erha$ap para#ss

$%an$a $en"an&

DS+

Pasen )en"a%a(an )ua#&

(e#uar"a pasen

)en"a%a(an pasen

)un%ah = 49 sehar&

pasen )en"a%a(an susah

)ene#an $an )en"un-ah

)a(anann-a.

DO+

pasen han-a

)en"habs(an 1:4 $ar 1

prn" -an" $ber(an&

pasen %a)pa( (urus&

pasen %a)pa( #e)ah&

bera% ba$an pasen %urun

6 ("& #n"(ar #en"an 30

2)

pasen )en"a#a) penn"(a%an

$en"an 2r%era has# +

, bera% ba$an pasen )enn"(a%

, #n"(ar #en"an pasen

N#a N'r)a# +

37&4 2) un%u( #a(,#a(

36& 2) un%u( an%a

, pasen %$a( )ua# $an )un%ah

, pasen )en"habs(an 1 p'rs

)a(an -an" $ber(an

2u(up sa$ar $an resp'nsf&

apa(ah $apa% )en"'n%r'#

)u#u%& $apa% ba%u( $an $apa%

)ene#an sa#*an-a sen$r.

3. Tn"(a%(an upa-a un%u(

$apa% )e#a(u(an pr'ses

)ene#an -an" efe(%f $en"an

2ara )e)ban%u pasen un%u(

)en"'n%r'# (epa#a.

4. An!ur(an pasen un%u(

s%raha% sebe#u) )a(an.

5. @er(an )a(an $en"an

per#ahan pa$a #n"(un"an -an"

%enan".

6. @er(an )a(anan $a#a)

p'rs se$(% %e%ap sern".

7. @er(an )a(anan $en"an

('nss%ens se%en"ah 2ar a%au

#una(.

. @er(an )a(anan %a)bahan

8)s. A"ar,a"ar;& b#a %$a( a$a

('n%ran$(as.>. U(ur bera% ba$an& #n"(ar

#en"an $an #n"(ar peru%

pasen.

/. K'#ab'ras $en"an $'(%er

$a#a) pen""unaan nas'"as%r2

%ube apab#a pasen %$a(

)a)pu un%u( )ene#an.

(erusa(an $a#a) )enen%u(an

p#han n%er*ens )e)ber(an

nu%rs:p#han ru%e )a(an -an"

%epa% -an" a(an $"una(an.

3.


10/16

10. K'#ab'ras $en"an ah# "

$a#a) )e)ber(an $e% %n""

(a#'r %n"" pr'%en& $an %n""

sera%.

11. K'#ab'ras $en"an $'(%er

$a#a) pe)beran )u#%*%a)n

$apa% )e)ban%u )e)enuh

asupan nu%rs pasen -an"

)e)#( )asa#ah )ene#an.

10.


11/16

)en"e#uar(an suara

$an pasen %a)pa(

berb2ara %erba%a,ba%a

berb2ara $en"an na$a n'r)a#

$an hn$ar per2a(apan -an"

2epa%.

6. @er(an

pasen !ara( $an a(%u un%u(

berb2ara saa% beresp'n

7. An!ur(an

'ran" %er$e(a%:(e#uar"a

)e)per%ahan(an

ber(')un(as $en"an pasen.

. Tun$a

per2a(apan !(a (#en #e#ah.

)en"uran" pen"e#uaran ener"

pasen.

5. A"ar pasen $apa% )en"er%

(a%a,(a%a -an" $u2ap(an

peraa% )aupun (e#uar"an-a.

6.


12/16

)en"a%a(an %$a(

)erasa(an sen%uhan

saa% $ber(an

s%)u#as

DO+

, pasen

%a)pa( %$a(

%erpen"aruh %erha$ap

s%)u#as

persen$an.

4. De(a% pasen $ar $aerah

pen"#ha%an -an" n'r)a#.

5. @er(an s%)u#as %erha$ap

rasa sen%uhan seper% ber(an

pasen sua%u ben$a.

6. @er(an #n"(un"an -an"

a)an $an n-a)an.

(erusa(an perasaan (ne%2

berpen"aruh buru( %erha$ap

(ese)ban"an:p'ss %ubuh $an

(esesuaan $ar "era(an -an"

)en""an""u a)bu#as& $an

$apa% )enn"(a%(an res('

%rau)a.

4. Pe)beran pen"ena#an

%erha$ap a$an-a 'ran":ben$a

$apa% )e)ban%u )asa#ah

perseps $an )en2e"ah

(e%er(e!u%an pasen.

5.


13/16

)an$ (e (a)ar

)an$ $an han-a

$#ap sehar se(a#&

Ke#uar"a pasen

)en"a%a(an pasen%$a( pernah

)en""'s'( "".

DO+

, Pasen

%a)pa( ('%'r& bau

ba$an& ra)bu% (usu%&

(u#% %a)pa( ('%'r&

bau )u#u%& "" ('%'r&

ADL pasen %a)pa(

$ban%u (e#uar"a.

G" pasen %a)pa( #ebh

bersh&

Ra)bu% %er#ha% rap.

4. @er(an a#a% ban%u -an"

$per#u(an un%u( %'#e%n"

8urna#& be$pan;.

5. @er(an (ese)pa%an un%u(

(ebershan 'ra#.6. @er(an #'%'n:%a#( se%e#ah

)e)bersh(an $r.

7. A!ar(an (e)an$ran pasen

$a#a) )e)bu(a (an2n"&

a%aupun )e#epas pa(aan se2ara

ber%ahap& na)un %$a(

$pa(sa(an !(a ('n$s pasen

buru(.

$en"an (e)anan -an" 'p%)a#.

5.

)en!a"a (ebershan )u#u%.

6.


14/16

DO+

, Pasen

%a)pa( !aran"berb2ara apab#a

%$a( $a!a(. K'n%a(

)a%a 8,;.

%er$e(a%:(e#uar"a

)e)per%ahan(an

ber(')un(as $en"an pasen.

(e(uran"ann-a.

4.


15/16

berubah p'ss

7. @ersh(an $an (ern"(an (u#%.

Ja"a#ah %enun %e%ap (ern".

. Ja"a (ebershan (u#%&

se)n)a# )un"(n hn$ar%rau)a $an panas %erha$ap (u#%

.


16/16

13. Anse%as berhubun"an

$en"an pr'"n'ss

pen-a(% pasen

Ds +- Ke#uar"a )en"a%a(an

2e)as $en"an

(ea$aan pen-a(%

pasen

D' +

- Ke#uar"a pasen

%a)pa( 2e)as

-Ke#uar"a pasen%a)pa( "e#sah

Se%e#ah $ber(an asuhan

(eperaa%an $harap(an

anse%as %era%as $en"an (r%era

has# +

-Ke#uar"a pasen %$a(%a)pa( 2e)as $an

"e#sah

- Ke#uar"a pasen

%a)pa( r#e(s

1.

Se#a#u a$a un%u( (e#uar"a pasen

3.

@na hubun"an sa#n" per2a-a

$en"an 'ran" %er$e(a%.4.

Per%ahan(an pr#a(u n-a%a $a#a)

)e#a(u(an pr'se$ur :

)ener)a pasen& #n$un"

pr*a2- pasen.

5.

@er pen"ua%an nf'r)as pa$a

(e#uar"a -an" %e#ah $ber(an

sebe#u)n-a.

1.

intervensi stroke baru

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