laporan pendahuluan asuhan keperawatan pasien dengan hipertensi heart disease

7/24/2019 Laporan Pendahuluan Asuhan Keperawatan Pasien Dengan Hipertensi Heart Disease

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LAPORAN PENDAHULUAN ASUHAN KEPERAWATAN PASIEN DENGAN HIPERTENSIHEART DISEASE (HHD)

I. KONSEP DASAR PENYAKIT

A. Definisi

Hipertensi heart isease aa!ah pen"a#it $ant%n& "an& ise'a'#an !eh hipertensi.

Hipertensi "an& ta# ter#ntr! a!a *a#t% "an& !aa eni'%!#an h"pertrph" paa +entri#e!#iri (L,H) .

Hipertensi heart isease ite&a#an 'i!a iete#si aan"a h"pertrph" paa +entri#e! #iri

se'a&ai a#i'at peninatan 'ertahap tahanan pe'%!%h arah peri+er an +entri#e! #iri. -%n&si+entri#e! se!aa hipertensi 'erh%'%n&an erat en&an pen"e'a' h"pertrph" an ter$ain"a

arters#!ersis #rner. Yan& epen&ar%hi h"pertrph" +entri#e! #iri aa!ah !aan"a

peninatan iast!i an aan"a fatr &eneti#.

/. Epiei!&i

0%!ah pasti penerita en&an HHD 'e!% i#etah%i en&an pasti1 na%n paa 'e'erapa

st%i ise'%t#an paa penerita hipertensi a#an 'er#e'an& en$ai pen"a#it $ant%n&. Seara%% resi# ter$ain"a L,H eninat paa penerita 'esitas %a #a!i !ipat. Se'an"a# 234

536 penerita hipertensi a#an en&a!ai resi# &a&a! $ant%n& an #nisi ini eninat %a

#a!i !ipat paa pria an *anita ti&a #a!i !ipat.

7. Pen"e'a'

Se'a' %taa ari hipertensi heart isease aa!ah hipertensi "an& 'er!an&s%n& #rnis.

Hipertensi paa ran& e*asa seniri ise'a'#an !eh 'e'erapa ha! iantaran"a8

9. Hipertensi esensia! "an& ter$ai paa :36 #as%s hipertensi paa ran& e*asa.;. Hipertensi se#%ner se'esar 936 ari #as%s hipertensi paa ran& e*asa "an& ise'a'#an

!eh aan"a #e!ainan paa &in$a!1 #e!ainan en#rin1 peninatan TIK !!.

D. Pathfisi!&i

Paa stai% per%!aan hipertensi1 h"pertrph" "an& ter$ai #nsentri# (if%s). /e!%

aa per%'ahan "an& 'erarti paa f%n&si ppa efe#tif +entri#e! #iri. Paa stai% se!an$%tn"a1a#i'at hipertensi "an& ter%s ener%s1 a#a hipertrpi en$ai ta# terat%r (e#sentri#). Paa

#nisi ini ter$ai pen%r%nan f%n&si ppa +entri#e! seara en"e!%r%h "an& 'era#i'at paa

pen%r%nan fra#si in$e#si1 peninatan te&an&an inin& +entri#e! paa saat sist!i#1 peninatan#ns%si #si&en tt $ant%n&1 serta pen%r%nan efe# e#ani# ppa $ant%n&. Knisi ini a#an

!e'ih iper'%r%# 'i!a ter$ai pen"a#it $ant%n& #rner.

Paa #nisi h"pertrph" a#a te#anan perf%si paa #rner a#an eninat an ii#%tien&an peninatan tahanan pe'%!%h #rner. Se'a&ai a#i'atn"a aan&an a!iran arah

#rner a#an 'er#%ran&.

Aa %a fatr %taa pen"e'a' pen%r%nan aan&an a!iran arah #rner "ait%89. Pene'a!an arteri #rner1 "ait% 'a&ian ari hiprtrph" %% tt p!s pe'%!%h arah

se!%r%h t%'%h. Ke%ian ter$ai retensi &ara an air "an& en&a#i'at#an 'er#%ran&n"a

p!iane pe'%!%h arah an eninatn"a tahanan perifer.


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;. Peninatan h"pertrph" en&a#i'at#an 'er#%ran&n"a #epaatan #api!er %nit tt $ant%n&

ter%taa paa h"pertrph" e#sentri#.

0ai fatr #rner paa hipertensi 'er#e'an& en$ai a#i'at pen"a#it1 es#ip%n tapa#se'a&ai pen"e'a' pat!&is "an& %taa ari &an&&%an a#ti+itas e#ani# +entri#e! #iri.

WOC

E. K!asifi#asi

-rn!ih e'a&i #e!ainan $ant%n& a#i'at hipertensi en$ai epat tinatan "ait%


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#at I 8 /esarn"a $ant%n& asih nra!1 'e!% ter!ihat #e!ainan $ant%n& paa peeri#saan EKG a%p%n

rai!&".

#at II 8 Tapa# #e!ainan atri% #iri paa peeri#saan EKG an aan"a s%ara $ant%n& #e4= (atria! &a!!p)se'a&ai tana aan"a h"pertrph" +entri#e! #iri.

#at III 8 Tapa# aan"a h"pertrph" +entri#e! #iri paa peeri#saan EKG an rai!&".

Tinat I, 8 Aan"a #e&a&a!an $ant%n& #iri.

-. Ge$a!a K!inis

Paa stai% ini hipertensi1 a#an tapa# tana4tana a#i'at aan"a ran&san&an

sipati# "an& #rni#. 0ant%n& 'eren"%t !e'ih epatan #%at. Ter$ai hiper sir#%!asi "an&%nin ia#i'at#an !eh peninatan a#tifitas an s"ste ne%rh%ra! isertai en&an

hiper+!%ia. Paa stai% !an$%t1 a#an ti'%! e#anise #pensasi paa tt $ant%n& 'er%pa

h"pertrph" +entri#e! #iri an peninatan tahanan pe'%!%h arah perifer. A#an tapa#sesa#nafas paa pasien !eh #arena aan"a &an&&%an iast!i.

G. Peeri#saan fisi#

Paa pa!pasi1 !eh #arena h"pertrph"1 a#a a#an iapat pena'ahan i#t%s ris. /i!ater$ai i!atasi +entri#e! #iri1 a#a i#t%s ris a#an 'er&eser #e#iri 'a*ah. Paa a%s#%!tasi a#an

ite%#an S= an 'i!a ter$ai i!atasi $ant%n& iapat tana4tana ins%fisiensi itra! re!ati+e.

H. Peeri#saan Pen%n$an&

Paa ft thra# psisi psterianterir pasien hiperthrph" #nsentri#1 'esar $ant%n&

a!a 'atas nra!. Pe'esaran $ant%n& #iri ter$ai 'i!a s%ah aa i!atasi +entri#e!

#iri.Terapat stensis arta paa hipertensi "an& #rni# an tana4tana 'en%n&an pe'%!%hpar% paa stai% pa"ah $ant%n& hipertensi.

Peeri#saan !a'ratri% arah r%tin "an& iper!%#an aa!ah peeri#saan %re% an

#reatinin %nt%# eni!ai f%n&si &in$a!1 an peeri#saan e!e#tr!it.

Paa peeri#saan EKG a#an ite%#an tana4tana h"pertrph" +entri#e! #iri.Peeri#saan E##ari&rafi apat enete#si h"pertrph" +entri#e! #iri seara ini "an&

ena#%p #e!ainan anati an f%n&sina! $ant%n&. Per%'ahan "an& apat i!ihat aa!ah89. Tana4tana hiper sir#%!asi paa stai% ini

;. Hipertrph" "an& #nsentri# a%p%n "an& e#sentri#

>. Di!atasi +enteri#e!"an& apat er%pa#an tana4tana pa"ah $ant%n&1 serta te#anan

a#hir iast!i +entri#e! #iri "an& eninat.

=. Tana4tana is#ei# paa stai% !an$%t.

I. ?ei#asi

Pen&'atan it%$%#an %nt%# en%r%n#an te#anan arah en$ai nra!1 en&'atipa"ah $ant%n& a#i'at hipertensi1 en%r%n#an r'iitas an rta!itas a#i'at pen"a#it

#ari+as#%!er1 an en%r%n#an fatr resi# terhaap pen"a#it #ari+as#%!er en&an

a#sia!.

II. KONSEP DASAR ASUHAN KEPERAWATAN

A. Pena$ian.


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Pena$ian if#%s#an paa #e!ainan fisi# a%p%n psi#is "an& iti'%!#an !eh HHD.

Aan"a ri*a"at hipertensi "an& !aa an aan"a ri*a"at hipertensi an pen"a#it $ant%n& paa

#e!%ar&a.Data asar pena$ian8

9. A#ti+itas@istirahatGe$a!a8 Aan"a #e!eahan1 !etih1 nafas pene# sapai sesa#

Tana 8 -re#%ensi en"%t $ant%n& eninat1 Per%'ahan iraa $ant%n&1 ta#ipneaan

;. Sir#%!asi

Ge$a!a8 Aan"a ri*a"at hipertensi1 aters#!ersis1 pen"a#it $ant%n& #rner an pen"a#it

sere'r+as#%!er.

Tana8 aan"a peninatan te#anan arah1 en"%t nai "an& $e!as paa aerah #artis1 $%&%!arisan raia!is. Den"%t nai fera!is e!a'at1 seanan paa nai pp!itea1ti'ia!is an rsa!is

peis en$ai !eah.

Ti'%! ta#i#ari a%p%n isritia1 teren&ar S= s%araatria! &a!!p.

Ter$ai per%'ahan *arna #%!it paa e#striitas1 s%h% in&in1 #%!it p%at1 siansis.

. Inte&ritas e&Ge$a!a8 Aan"a per%'ahan #epri'aian1 ansietas1 epresi1 arah1 fatr4fa#tr stress %!tip!e

Tana8 &e!isah1 pen"epitan !apan& perhatian1 enan&is1 tt%#a "an& te&an&1 peninatan

p!a 'iara1 serin& en&he!a nafas.=. E!einasi

Ge$a!a8 aan"a &an&&%an paa &in$a! se#aran& a%p%n saat !a!%.

2. ?a#anan@airanGe$a!a< Ke'iasaan enns%si a#anan tin&&i &ara1 !ea# a%p%n #!ester!. Aan"a

perasaan %a! an %ntah1 per%'ahan 'erat 'aan1 pen&&%naan e%riti#.

Tana8 /erat 'aan nra! ata% 'esitas. Ti'%! eea (%% ata%p%n tertent%)

5. Ne%rsensri

Ge$a!a< Aan"a #e!%han p%sin&1 #epa!a 'eren"%t1 sa#it #epa!a s%' #sipita!1 #e!eahan paasa!ah sat% sisi t%'%h1 &an&&%an pen&e!ihatan1 an apat ter$ai epista#sis.

. N"eri@ #etia#n"aanan

Ge$a!a< ter$ai an&ina1 n"eri hi!an& ti'%! paa t%nai se'a&ai ini#asi aan"a arteris!ersis1sa#it #epa!a #sipita! 'erat1 n"eri a'en.

B. PernafasanGe$a!a8 ispne 'er#aitan en&an a#ti+itas1 ta#ipne1 rtpnea1 'at%# tanpaata% en&an sp%t%1

aan"a ri*a"at er##.

Tana< pen&&%naan tt a#sesri pernafasaan1 aan"a '%n"i nafas ta'ahan1 siansis.

:. Pe'e!a$aran

Ge$a!a< -a#tr resi# ri*a"at #e!%ar&a hipertensi1arters#!ersis1 pen"a#it $ant%n&1 D?1 pen"a#it

sere'r+as#%!er@&in$a!. -a#tr ras1 pen&&%naan 'at@a!h!.


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/. Dia&nsa #epera*atan

Dia&nsa #epera*atan "an& serin& %n%! paa pasien en&an hipertensi heart esease aa!ah. ?inia!#an a#ti+itas+as#nstri#si "an&

apat eninat#ann"eri seperti 'at%#

pan$an&1 e'%n%#

!!.

=. K!a'rasi pe'erian

ana!&esi

9. Ka$i fre#%ensi1

#ea!aan pernafasan

an e#spansi aa.

e'ant%#esei'an&an antara

s%p!ai an #e'%t%han

#si&en.

>. A#ti+itas 'ertahapene&ah peninatan#er$a $ant%n& seara

ti'a4ti'a1

e'eri'ant%an ses%ai

#e'%t%han a#anenrn&

eaniri#an pasien

a!a 'era#ti+itas.

9. ?einia!#an

sti%!asi aneninat#an re!a#sasi.

;. Tina#an "an&en%r%n#an te#anan

+as%!ar an e'!#

respn sipatis efe#tif

en&%ran&i rasa sa#itan #p!i#asin"a.

>. A#ti+itas

+as#nstri#si a#aneninat#an te#anan

+as%!ar $ant%n&.

=. Unt%# en%r%n#an@en&ntr! n"eri

en&an en&ntr!

ran&san&an s"stesaraf sipatis.

9. -re#%ensi nafas'iasan"a eninat1

ispnea an ter$ai

peninatan #er$anafas. E#spansi aa

"an& ter'atas

enana#an aan"a


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=. =.

GDA

Sete!ah i!a#%#an

tina#an pera*atan

iharap#an perf%si

$arin&an ae#%atseperti a#ra! han&at1

nai perifer #%at1tana +ita! nra!1

rientasi pasien

'a&%s1 rasan"eri

'er#%ran&.

;. Tin&&i#an psisi#epa!a an /ant% a!a

en&%'ah psisi.

>. /ant% pasien

en&atasi #eta#%tan

a!a 'ernafas

=. K!a'rasi pe'erian

#si&en ta'ahan

9. A*asi per%'ahan

enta! ntin%e sepertieas1 'in&%n&1 !etar&i1

pin&san

;. Drn& !atihana#tif@pasif

>. Panta% pernafasan

=. #a$i f%n&si&astrintestina! an

per#eihan

n"eri aa

;. psisi #epa!a !e'ih

tin&&i e%nin#anespansi par% an

e%ah#anpernafasan.Pen&%'ahan psisi

eninat#an

pen&isian se&en par%

"an& 'er'ea sehin&&aeper'ai#i if%si &as

.

>. Perasaan ta#%t'ernafas eninat#an

ter$ain"a hip#seia

=. ?ea#sia!#an

'ernafas an

en%r%n#an #er$anafas.

9. Perf%si sere'ra!

!an&s%n& 'er#aitanen&an %rah $ant%n&

;. Latihan a#tif @pasifen%r%n#an statis

+ena1 eninat#ana!iran 'a!i# +ena1

en%r%n#an resi#

tr'f!e'itis.

>. Ppa $ant%n& "an&

&a&a! apat

enet%s#an istresspernafasan. Dispnea

"an& ter$ai ti'a4ti'a

en%n$%#an aan"atr'e'!i par%.

=. Unt%# en&etah%iapa# ne&ati+e paa

perf%si an f%n&si

r&an terse'%t.


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2.

5.

2.

5.

Sete!ah i!a#%#an

tina#an pera*ataniharap#an pasien

en%n$%#an tana

+ita! a!a 'atas"an& apat iteria1

'e'as ari &e$a!a

&a&a! $ant%n&1

Sete!ah i!a#%#antina#an pera*atan

iharap#an

pen&etah%an pasien

2. K!a'rasi

peeri#saan !a' /UN1

7reatinin1 e!e#tr!it1GDA

9. Ka$i fre#%ensi aniraa $ant%n&

;. 7atat '%n"i $ant%n&

>. Ka$i #%!it terhaap

p%at an siansis

=. Ka$i per%'ahan paa

sensri seperti !etar&i1'in&%n&1 eas1 epresi.

2. /eri#an istirahat

en&an !in%n&an "an&tenan&1 /ant% pasien

en&hinari stress

5. K!a'rasi pe'erian#si&en en&an

#an%!@as#er ses%aiini#asi.

. K!a'rasi pe'erian+asi!atr

9. 0e!as#an tentan&

f%n&si $ant%n& nra!an #e!ainan "an&

ia!ai !eh pasien

;. K%at#an rasina!

pen&'atan

2. Di&%na#an se'a&ai

iniatr perf%si@f%n&si

r&an.

9. /iasan"a ter$aita#i#ari se'a&ai

#pensasi pen%r%nan

#ntra#ti!itas +entri#e!.

;. Iraa &a!!p %%

ihasi!#an ari

+entri#e! "an& istensi>. P%at en%n$%#an

pen%r%nan perf%si

a#i'at pen%r%nan %rah$ant%n&

=. Unt%# en&etah%i

ae#%atn"a perf%sisere'ra! terhaap

pen%r%nan %rah

$ant%n&.

2. stress en&hasi!#an+as #nstri#si "an&

eninat#an te#anan

arah an

eninat#an fre#%ensi#er$a $ant%n&

5.Unt%# eninat#an#eseiaan #si&en

%nt%# #e'%t%han

i#ar an $arin&an

serta e!a*an efe#hip#sia.

. +asi!atr

i&%na#an %nt%#eninat#an %rah

$ant%n&

9. Pen&etah%an tentan&

prses pen"a#it

anharapan apate%ah#an #etaatan

paa pr&ra

pen&i'atan.


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tentan& pen"a#itn"a'erta'ah1

?e!a#sana#an

therapi%nt%#en%r%n#an epise

'er%!an& anene&ah#p!i#asi1e!a#%#a

n per%'ahan p!a

peri!a#% "an& per!%.

>. Dis#%si#an tentan&

'at1 t%$%an an efe#sapin&1 'eri#aninstr%#si seara +er'a!

a%p%n tert%!is.

=. 0e!as#an an

is#%si#an peran pasien

a!a en&ntr! fatrresi# an fatr

pe'erat.

2. /eri#an #esepatan

pasien %nt%#

enan"a#an1

enis#%si#an asa!ahan e'%at per%'ahan

p!a hi%p "an& per!%.

;. Peahaanpr&ra1 'at an

pe'atasan apat

eninat#an#er$asaa %nt%#

en&ntr! &e$a!a.>. Peahaan#e'%t%han terapi%ti#

an pentin&n"a

pe!apran efe# sapin&

apat ene&ahter$ain"a #p!i#asi

'at.

=. ?ena'ah#anpen&etah%an an

e%nin#an pasien

%nt%# e'%at#ep%t%san 'erasar#an

infrasi seh%'%n&an

en&an ntr! #nisian ene&ah

'er%!an&@ #p!i#asi.

2. Knisi #rnis serin&

e!eah#an#eap%an #pin& an

#apasitas %#%n&an

pasien an ran&

tere#at.

Kiri#an Ini !e*at Eai!/!&This/er'a&i #e T*itter/er'a&i #e -ae'#/a&i#an #e Pinterest
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laporan pendahuluan asuhan keperawatan pasien dengan hipertensi heart disease

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