II.

ANALISA DATA
Data Fokus
Data subjektif:
1. Klien mengatakan

Etiologi

Masalah Keperawatan

Kebiasaan mengkonsumsi
alkohol

mulut, kaki, dan

tangan kanan
bergerak-gerak sendiri

Penimbunan lemak/kolesterol
yang meningkat dalam darah

tanpa bisa di stop

selama 3 hari sebelum
masuk rumah sakit.
2. Klien mengatakan

Lemak yang sudah nekrotik

dan berdegenerasi

memiliki riwayat
kebiasaan ngerokok
dan minum alcohol.
3. Keluarga klien
mengatakan yang

Menjadi kapur/mengandung
kolesterol dengan infiltrasi
limfosit (trombus)

menjadi sumber
stressor adalah
masalah ganti rugi

Ateriosklerosis

tanah.
Data Objektik:

Trombus/emboli dicerebral

1. Tekanan darah pasien

saat pengkajian
140/70 mmHg

Obstruksi aliran darah ke

otak

2. Bicara klien tidak

jelas, karena mulut
sebalah kanan
bergerak-gerak sendiri
3. Kulit teraba hangat

Penurunan aliran darah ke

otak

Resiko ketidakefektifan
perfusi jaringan otak

dan perfusi perifer

baik, kelembaban
cukup

Data Fokus
Data subjektif:

Resiko ketidakefektifan
perfusi jaringan otak

Etiologi
Penurunan aliran darah

1. Klien mengatakan
mulut, kaki, dan
tangan kanan bergerakgerak sendiri tanpa

Penurunan aliran oksigen ke

otak

bisa di stop selama 3

hari sebelum masuk
rumah sakit.

Stroke iskemik

2. Keluarga klien
mengatakan yang
menjadi sumber

Penuruna aliran darah ke

otak kiri

stressor adalah
masalah ganti rugi
tanah.

Hemiparase kanan

Data Objektik:
3. Klien terlihat korea
4. Klien tidak mampu
menggerakkan

Penurunan fungsi motorik

dan muskuloskeletel

ekstremitas atas dan

bawah bagian kanan
5. Bicara klien tidak
jelas, karena mulut

Hambatan mobilitas fisik

Masalah Keperawatan
Hambatan mobilitas fisik

sebalah kanan
bergerak-gerak sendiri
6. Kulit teraba hangat dan
perfusi perifer baik,
kelembaban cukup
Data Fokus
Data subjektif:
1. Klien mengatakan

Etiologi

Masalah Keperawatan

ebiasaan mengkonsumsi
alkohol

mulut, kaki, dan

tangan kanan bergerakgerak sendiri tanpa
bisa di stop selama 3
hari sebelum masuk
rumah sakit.

Pembentukan trigliserida
secara berlebihan,
menurunnya jumlah keluaran
trigliserida dari hati,
menurunnya oksidasi asam
lemak

2. Keluarga klien
mengatakan yang
menjadi sumber
stressor adalah
masalah ganti rugi

Akumulasi lemak secara

bertahap di dalam sel-sel hati

tanah.
Data Objektik:

Terbentuk jaringan parut

yang meluas

1. SGOT dan
SGPTmeningkat
SGOT 157 U/L dan
SGPT 113 U/L

Fungsi hati terganggu

2. Kulit teraba hangat dan

perfusi perifer baik,
kelembaban cukup

Resiko gangguan fungsi hati

Resiko gangguan fungsi hati

III. RUMUSAN DIAGNOSA MASALAH

No

Rumusan Diagnosa Masalah

Resiko ketidakefektifan perfusi jaringan otak d/d Klien mengatakan mulut, kaki, dan
tangan kanan bergerak-gerak sendiri tanpa bisa di stop selama 3 hari sebelum masuk
rumah sakit. Klien mengatakan memiliki riwayat kebiasaan ngerokok dan minum
alcohol. Keluarga klien mengatakan yang menjadi sumber stressor adalah masalah
ganti rugi tanah. Tekanan darah pasien saat pengkajian 140/70 mmHg. Bicara klien
tidak jelas, karena mulut sebalah kanan bergerak-gerak sendiri.Kulit teraba hangat dan
perfusi perifer baik, kelembaban cukup

Hambatan mobilitas fisik b/d perubahan sistem saraf pusat d/d klien mengatakan
mulut, kaki, dan tangan kanan bergerak-gerak sendiri tanpa bisa di stop selama 3 hari
sebelum masuk rumah sakit. Keluarga klien mengatakan yang menjadi sumber stressor
adalah masalah ganti rugi tanah. Klien terlihat korea. Klien tidak mampu
menggerakkan ekstremitas atas dan bawah bagian kanan.Bicara klien tidak jelas,
karena mulut sebalah kanan bergerak-gerak sendiri. Kulit teraba hangat dan perfusi
perifer baik, kelembaban cukup

Resiko gangguan fungsi hati d/d Klien mengatakan mulut, kaki, dan tangan kanan
bergerak-gerak sendiri tanpa bisa di stop selama 3 hari sebelum masuk rumah sakit.
Keluarga klien mengatakan yang menjadi sumber stressor adalah masalah ganti rugi
tanah.SGOT dan SGPT meningkat ,SGOT 157 U/L dan SGPT 113 U/L. Kulit teraba
hangat dan perfusi perifer baik, kelembaban cukup

IV. INTERVENSI
A. Risiko ketidakefektifan perfusi jaringan otak
NOC
Circulation Status
Indicator:
1. No deviation from normal range of the systolic and diastolic blood
pressure

2. No orthostatic hypotension
3. No Impaired cognition
4. No sign and symptom of paresthesia
NIC
Peripheral sensation management
1. Monitor for paresthesia: numbness, tingling, hyperesthesia, and
hypoesthesia
Rational: to avoid the paresthesia incident of the patient and give
immediate action to control the incident
2. Monitor for thrombophlebitis and deep vein thrombosis
Rational: avoid the other causes of pain to the patient and prevent the postthrombotic syndrome
3. Instruct patient to visually monitor position of body parts, if
proprioception is impaired
Rational: the sense of proprioception is disturbed in many neurological
disorder.
Cerebral Perfusion Promotion
1. Consult with physician to determine hemodynamic parameters, and
maintain hemodynamic parameters within this range
2. Induce hypertention with volume expantion or intropic or vasocontictive
agents, as ordered to maintain hemodynamic parameters and maintain
cerebral perfusion pressure (CPP)
3. Administer volume expander to maintain hemodynamic parameters, as
ordered
4. Maintain serum glucose level within normal range
5. Avoid neck flexion or extreme hip/ knee flexion
6. Monitor for signs of bleeding
7. Monitor neurological status
8. Calculate and monitor cerebral perfusion pressure
9. Monitor main arterial pressure
10. Monitor CVP
11. Monitor determinants of tissue oxygen delivery (e.g., PaCO 2, SaO2,
and hemoglobin level and cardiac output), if available
12. Monitor lab values for changer in oxygenation or acid-base balance, as
appropriate

13. Monitor intake and output

B. Hambatan mobilitas fisik
NOC
Exercise Therapy: Ambulation
Indicator:
1. Substantially compromised the coordination
2. Substantially compromised the muscle movement
3. Substantially compromised the joint movement
4. Substantially compromised the moves with ease.
NIC
Exercise therapy: Ambulation
1. Dress patient in nonrestrictive clothing
Rational: easier patient to move
2. Provide low-height bed, as appropriate
Rational: provide the easiness for the patient to move out the bed
independently
3. Assist patient to sit on side of bed to facilitate postural adjustment
Rational: avoid the stiffness of the spine
4. Encourage patient to implement ROM active and passive exercise
Rational: exercise the paralyzed hand to maintain the flexibility of the
joints.
5. Assist patient with initial ambulation and as needed
Rational: support patient movement and maintain the safety
6. Consult physical therapist about ambulation plan, as needed
Rational: serving professional advice or opinion correspond to the patient
health status

C. Risiko gangguan fungsi hati

NOC

Risk control alcohol use

1. Acknowledge risk of alcohol misuse
2. Commits to alcohol use control strategies
3. Uses personal support system to control alcohol misuse
NIC
Activity therapy
1. Collaborate with occupational, physical, and/or recreational therapist in
planning and monitoring an activity program, as appropriate.
2. Assist patient to identify preferences for activities.
3. Assist patient/family to adapt enviroment to accommodate desired activity.
4. Assit with regular physical activities (e.g ambulation, transfer, turning, and
personal care) as needed
5. Make enveronment safe for contiunous large muscle movement, as
indicated.
6. Monitor emotional, physical, social, and spiritual response to activity
Surveillance
1. Determine patient's health risk(s), as appropriate
Rational: determining the possibilities of complication of the disease
2. Ask patient about recent sign, symptoms, or problem
Rational: Assessing the current health status whether it is become better or
worse
3. Monitor neurological status
Rational: to detect the presence of neurological disease or injury
4. Monitor nutritional status, as appropriate
Rational: to avoid the malnutrition cause by the disease
5. Monitor for sign and symptom of fluid and electrolyte imbalance
Rational: electrolyte imbalance will cause loss of body fluid from
prolonged vomiting, diarrhea, sweating, or high fever, malabsorption, and
so on
6. Compare current status with previous status to detect improvement and
deterioration in patient's condition.

Rational: Determining the health status of the patient whether it is become

better or worse

Referensi
Bulechek, Gloria M, dkk. 2013. Nursing Intervention Classification
(NIC): Sixth Edition. USA: Elsevier
Moorhead, Sue, dkk. 2013. Nursing Outcome Classification (NOC): Fifth
Edition. USA: Elsevier.
NANDA NIC-NOC. 2015. Aplikasi Asuhan Keperawatan Berdasarkan
Diagnosa Medis & NANDA NIC-NOC. Jogjakarta: Mediaction.