Diagnosa Keperawatan :

1. Hambatan mobilitas fisik berhubungan dengan hemichorea ekstremitas dextra

2. Resiko ketidakefektifan perfusi jaringan otak berhubungan dengan embolisme

Analisa Data :

No Data Fokus Analisis Data Rumusan Maslah

1. DS : Suplai darah Hambatan
&O2 menurun
Pasien mengatakan mobilitas fisik

mulut, kaki, dan tangan berhubungan

Hipoksia
dengan
bergerak-gerak sendiri Cerebri berhubungan
tanpa bisa stop sejak 3 Infak jaringan dengan
hari sebelum masuk otak hemichorea
rumah sakit. Kerusakan ekstremitas
pusat gerakan dextra
DO : motorik di
Mulut kanan dan anggota lobus frontalis
gerak bagian kanan Hambatan
pasien tampak bergerak- mobilitas fisik.
gerak sendiri.
Motorik :

---- 5555

---- 5555

2. DS : DM, HT, Risiko

Pasien mengatakan Alkohol, Sirosis ketidakefektifan
Hati
memiliki riwayat minum perfusi jaringan
alkohol/ bir 1 botol setiap Penimbunan otak
lemak
hari. berhubungan

Pasien mengatakan Arterosklerosis dengan

embolisme
memiliki kebiasaan Suplai O2
 merokok sejak umur 22 menurun di
otak
tahun sebanyak 2 s/d 3
bungkus sehari dan
Risiko
akhirnya berhenti sejak Ketidakefektifan
tahun 1999 yang lalu. perfusi jaringan
otak.

DO :
Tekanan Darah : 140/70
mmHg
Respirasi : 18x/menit
Nadi : 88x/menit
SGPT : 113 U/L

Intervensi Keperawatan

Rencana Keperawatan
No Diagnosa
Dx Keperawatan Tujuan dan Kriteria
Intervensi
Hasil
1 Hambatan mobilitas NOC NIC
. fisik berhubungan Exercise Therapy : Activities :
dengan hemichorea Ambulation Collaborate with occupational,
ekstremitas dextra
Indicator : physical, and/or recreational
1. Substantially therapist in planning and
compromised the monitoring an activity program,
coodination. as appropriate.
2. Substantially Determine patient's commitment
compromised the ti increasing frequency and/or
muscle movement. range of activity
3. Substantially Assist to choose activities
compromised the joint consistent with physical,
movement. psycological, and sosial
4. Substantially capabilities.
compromised the moves Assist to focus on what patient
with ease. can do, rather than on deficits
Assist patient to identify
preferences for activities.
Assist patient to identify
meaningful activities.
Assist patient/ family to identify
deficits in activity level
Instruct patient/family how to
perform desired or prescribed
activity.
Assist patient/family to adapt
enviroment to accommodate
desired activity.
Provide activities to increase
attention span in consultation
with OT.
Facilities activity substitution
when patient has limitations in
time, energy, or movement.
Assit with regular physical
activities (e.g ambulation,
transfer, turning, and personal
care) as needed
Make enveronment safe for
contiunous large muscle
 movement, as indicated.
Provide motor activity to relieve
muscle tension
Provide positive reinforcement
for participation in activities.
Assist patient to develop self
motivation and reinforcement.
Monitor emotional, physical,
social, and spiritual response to
activity
Assist patient/family to monitor
own progress toward goal
achievement.

2 Resiko NOC NIC

. ketidakefektifan Suggested Outcome : Consult with physician to
perfusi jaringan otak 1. Acute Confusion level determine hemodynamic
berhubungan dengan
2. Agitation Level parameters, and maintain
embolisme
3. Cognition hemodynamic parameters within
4. Neurological Status this range
5. Neurological Status : Induce hypertention with
Central Motor Control volume expantion or intropic or
6. Neurological Status : vasocontictive agents, as
Consciosness ordered to maintain
7. Seizure Control hemodynamic parameters and
8. Tissue Perfusion : maintain cerebral perfusion
Cellular pressure (CPP)
9. Tissue Perfusion : Administer and titrate
Cerebral vasoactive drugs, as ordered to
mentain hemodynamic
 parameters
Administer agents to expand
intravascular volume, as
appropriate (e.g colloid, blood
product, and crystalloid)
Administer volume expander to
maintain hemodynamic
parameters, as ordered
Monitor prothrombin time, and
partial tromboplastin time, if
using hetastarch as a volume
exvander
Administer reologic agents ( e.g
low-dose innaitol or low
molecular weight dextrans, as
ordered
Phlebotomize patient as
apropirate, to maintain
hematocrit level in desired range
Maintain serum glucose level
within normal range
Avoid neck flexion or extime
hip/ knee flexion
Keep p CO2 level at 25 mmHg
oe greater
Administer calcium channel
blockers, as ordered
Administer vasopressin, as order
Administer and monitor effect
of osmotic and loop active
 diuretic and corticosteroid
Administer pain medication as
appropriate
Administer anticoagulant
medication, as ordered
Administer antiplatelet
medication as ordered
Administer trombolitic
medication as ordered
Monitior patient protrombin
time and partial tromboplastin
time to keep one to two time
normal, as appropriate
Monitor for anti coagulante
terapy side effect
Monitor for signs of bleeding
Monitor neurological status
Calculate and monitor cerebral
perfusion pressure
Monitor patient ICP and
neurological respon to care
activities
Monitor main arterial pressure
Monitor CVP
Monitor PAWP and PAP
Monitor respiratory status
(e.g, rate, rythhm, and depth
of respirations, PO2, PCO2,
PH, and bicarbonate levels).
Auscultate lung sounds for
 crackles or other adventitious
sounds for crackles or other
adventitious sounds
Monitor for signs of fluid
overload (e.g. ronchi, jugular
venous distention (IVD),
edema and invrease in
pulmonary secretions
Monitor determinants of
tissue oxygen delivery (e.g.,
PaCO2, SaO2, and
hemoglobin level and cardiac
output), if available
Monitor lab values for
changer in oxygenation or
acid-base balance, as
appropriate
Monitor intake and output