LAPORAN RESUME KLIEN

Nama Mahasiswa : Muhammad Rakha Akbar, S.Kep

NIM : 1730913310027
Kelompok :B
Tanggal Praktek/Minggu ke : 8 Januari-13 Januari 2018/ IX
Tanggal/Jam Pengkajian : 9 Januari 2018/22.00
Tanggal/Jam MRS : 7 Januari 2018 /13.00

1. Identitas Pasien:
Nama : Ny. S
Umur : 48 th
Jenis Kelamin : Perempuan
Alamat : Martapura lama
Pendidikan Terakhir :-
Suku : Banjar
Agama : Islam
Status Perkawinan : Menikah
Pekerjaan : Tidak bekerja
No. Rekam Medik : 1-37-xx-xx
Diagnosis Medis : SAH dan ICH

2. Alasan Masuk (Keluhan Utama) :

Penurunan kesadaran
3. Riwayat Penyakit:
Pasien mengalami penurunan kesadaran pada pukul setengah 6 pagi SMRS, ketika
sedang beraktifitas, mendadak, mengalami nyeri kepala sebelum mengalami penurunan
kesadaran dan tidak ada muntah. Kemudian dibawa ke RS Ansari Saleh kemudian
dirujuk ke RSUD Ulin Banjarmasin.

4. Data Pengkajian
DS:
 -
DO:
 Pasien mengalami penurunan kesadaran dengan GCS E2 V2 M4
 Pasien terlihat lemah
 Adanya terlihat pendarahan pada hasil CT Scan
5. Pengobatan yang didapat saat ini
Citicoline 2 x 250 mg, Ranitidine 2 x 50 mg, Program manitol

6. Analisis Data
Data
Etiologi Masalah
Data Obyektif Data Subyektif
 RR : 32 x / menit  Keluarga pasien Cedera otak ( SAH Penurunan kapasitas
 SpO : 90% dengan
2 mengatakan pasien dan ICH) adaptif intrakranial
terpasang NRBM mengalami sesak ………………… ……………………
dengan dosis 10 lpm ………………… ……………………
 Adanya bunyi ronchi ………………… ……………………
pada suara nafas
………………… ……………………
pasien
…………………

Diagnosis Keperawatan
1. Penurunan kapasitas adaptif intrakranial b.d cedera otak ( SAH dan ICH)

Rencana Asuhan Keperawatan

NOC NIC
Status Neurologis: Kesadaran Manajemen edema serebral
Setelah dilakukan tindakan keperawatan 1. Monitor status pernafasan
diharapkan pasien: 2. Berikan diuretik osmotik
- Pasien mampu membuka mata apabila 3. Monitor intake dan output
dipanggil 4. Kaji TTV
- Pasien mampu merespons panggilan 5. Lakukan latihan ROM pasif
- GCS meningkat

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Implementasi
No. Dx Hari/tanggal/jam Tindakan
1. Selasa /9 Januari 2018/22.00 Airway Management
WITA 1. Monitor status pernafasan
2. Berikan diuretik osmotik
3. Monitor intake dan output
4. Kaji TTV
5. Lakukan latihan ROM pasif
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Catatan Perkembangan
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S :-
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O : Pasien masih lemah dan GCS pasien tidak meningkat
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A : Masalah belum teratasi
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P : Lanjutkan intervensi
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Banjarmasin, 10 Januari 2018

Mahasiswa,

(Muhammad Rakha Akbar, S.Kep)