HERNIA
A. PENGKAJIAN
1. Biodata:
a. Identitas klien
2) Usia : 3 bulan
4) Agama : Islam
7) Pekerjaan :-
8) No. Rm : 858310
1) Nama : Ny “K”
2) Umur : 28 tahun
4) Pekerjaan :-
3. Triage
4. Pengkajian Primer
36,5ºC
5. Pemeriksaan fisik
=15 (M-6,E-4,V-5)
c. Tanda-tanda vital
d. Antropometri
Panjang badan : 48 cm
6. Pemeriksaan Diagnostic
a. LABNomor RM : 857821
b. Nama Pasien : An. N
c. Jns Kelamain/Tgl Lahir : Laki-Laki
d. Nomor Lab : 033
e. Diagnosa : Hernia
f. Unit Pengatar : Bedah IGD
g.
h.
i. PEMERIKS
AAN k. Nilai l. Sat
j. Hasil
m. HEMATOL Rujukan uan
OGI
q. Hematologi r. s. t.
Rutin
u. WBC v. 14.8 w. 4.00- x. 10^
6 10.0 3/ul
y. RBC z. 3.10 aa. 4.00- bb. 10^
6.00 6/ul
cc. HGB dd. 9.2 ee. 12.0- ff. gr/
16.0 dl
gg. HCT hh. 27.9 ii. 37.0- jj. %
48.0
kk. MCV ll. 90.0 mm. 80.0- nn. Fl
97.0
oo. MCH pp. 29.7 qq. 26.5- rr. Pg
33.5
ss. MCHC tt. 33.0 uu. 31.5- vv. dr/
35.0 dl
ww. PLT xx. 729 yy. 150-400 zz. 10^
3/ul
aaa. RDW-SD bbb. 47.9 ccc. 37.0- ddd. Fl
54.0
eee. RDW-CV fff. 14.9 ggg. 10.0- hhh.
15.0
iii. PDW jjj. 9.3 kkk. 10.0- lll. Fl
18.0
7. Therapy
b. Peracetam 50 mg/8jam/intravena
cccccccc.
qqqqqqqq.
rrrrrrrr.
ssssssss.
tttttttt.
uuuuuuuu.
vvvvvvvv.
wwwwwwww.
xxxxxxxx.
yyyyyyyy.
zzzzzzzz.
aaaaaaaaa.
ccccccccc.
hhhhhhhhhhhhhhhh.
iiiiiiiiiiiiiiii.
jjjjjjjjjjjjjjjj.
llllllllllllllll.
mmmmmmmmmmmmmmmm.
nnnnnnnnnnnnnnnn.
oooooooooooooooo.
pppppppppppppppp.
qqqqqqqqqqqqqqqq.
rrrrrrrrrrrrrrrr.
ssssssssssssssss.
tttttttttttttttt. IMPLEMENTASI DAN
EVALUASI
uuuuuuuuuuuuuuuu.
vvvvvvvvvvvvvvvv.
H xxxxxxxxxxxxxxxx.
zzzzzzzzzzzzzzzz.
aaaaaaaaaaaaaaaaa. Im bbbbbbbbbbbbbbbbb.
Ja
wwwwwwwwwwwwwwww.
yyyyyyyyyyyyyyyy. plementasi Evaluasi
Tg
ccccccccccccccccc.
ggggggggggggggggggg.
ccccccccccccccccccccc.
1. Mengkaji nyeri secara komprehensif bbbbbbbbbbbbbbbbbbbbbb
Se 16. dengan PQRST S : Orang tua Klien
hhhhhhhhhhhhhhhhhhh.
jjjjjjjjjjjjjjjjjjjjjjj. Hasil: Ibu klien mengatakan
ddddddddddddddddd.
iiiiiiiiiiiiiiiiiii. mengatakan nyeri pada buah sakar anaknya
eeeeeeeeeeeeeeeee.
jjjjjjjjjjjjjjjjjjj.
ddddddddddddddddddddd.
anaknya, nyeri yang dirasakan mengeluh nyeri
fffffffffffffffff.
kkkkkkkkkkkkkkkkkkk.
eeeeeeeeeeeeeeeeeeeee.
anaknya hilang timbul, wajah cccccccccccccccccccccccc. O
ggggggggggggggggg.
lllllllllllllllllll.
fffffffffffffffffffff.
meringis dengan skala nyeri 3, nyeri : Ekspresi wajah nampak
hhhhhhhhhhhhhhhhh.
mmmmmmmmmmmmmmmmmmm.
ggggggggggggggggggggg.
bertambah pada saat menangis. meringis.
iiiiiiiiiiiiiiiii.
nnnnnnnnnnnnnnnnnnn.
hhhhhhhhhhhhhhhhhhhhh.
kkkkkkkkkkkkkkkkkkkkkkk. dddddddddddddddddddddddd.
jjjjjjjjjjjjjjjjj.
ooooooooooooooooooo.
iiiiiiiiiiiiiiiiiiiii. Mengobservasi tanda- A : Masalah belum teratasi.
kkkkkkkkkkkkkkkkk.
ppppppppppppppppppp.
jjjjjjjjjjjjjjjjjjjjj. tanda vital eeeeeeeeeeeeeeeeeeeeeeee. P
lllllllllllllllll.
qqqqqqqqqqqqqqqqqqq.
kkkkkkkkkkkkkkkkkkkkk.
lllllllllllllllllllllll. (nadi, suhu, : Lanjutkan intervensi 1, 2, 3
mmmmmmmmmmmmmmmmm.
rrrrrrrrrrrrrrrrrrr.
lllllllllllllllllllll.
pernafasan) 1. Kaji tingkat
nnnnnnnnnnnnnnnnn.
sssssssssssssssssss.
mmmmmmmmmmmmmmmmmmmmm.
mmmmmmmmmmmmmmmmmmmmmmm. nyeri.
ooooooooooooooooo.
ttttttttttttttttttt.
nnnnnnnnnnnnnnnnnnnnn. 2. Observasi tanda-
Hasil :
ppppppppppppppppp.
uuuuuuuuuuuuuuuuuuu.
ooooooooooooooooooooo. tanda vital
nnnnnnnnnnnnnnnnnnnnnnn. N
qqqqqqqqqqqqqqqqq.
vvvvvvvvvvvvvvvvvvv.
ppppppppppppppppppppp. 3. Ajarkan teknik
: 120x/menit
rrrrrrrrrrrrrrrrr.
wwwwwwwwwwwwwwwwwww.
qqqqqqqqqqqqqqqqqqqqq. relaksasi.
sssssssssssssssss. ooooooooooooooooooooooo.
rrrrrrrrrrrrrrrrrrrrr. S 4. Memberikan
0
ttttttttttttttttt. : 37 C
xxxxxxxxxxxxxxxxxxx.
sssssssssssssssssssss. analgetik
uuuuuuuuuuuuuuuuu.
yyyyyyyyyyyyyyyyyyy.
16. ppppppppppppppppppppppp. P ffffffffffffffffffffffff.
vvvvvvvvvvvvvvvvv.
zzzzzzzzzzzzzzzzzzz.
: 32 x/menit gggggggggggggggggggggggg.
wwwwwwwwwwwwwwwww.
aaaaaaaaaaaaaaaaaaaa. hhhhhhhhhhhhhhhhhhhhhhhh.
qqqqqqqqqqqqqqqqqqqqqqq.
xxxxxxxxxxxxxxxxx.
bbbbbbbbbbbbbbbbbbbb. iiiiiiiiiiiiiiiiiiiiiiii.
yyyyyyyyyyyyyyyyy.
cccccccccccccccccccc.
ttttttttttttttttttttt. jjjjjjjjjjjjjjjjjjjjjjjj.
1. Mengkaji tingkat kecemasan (ringan, kkkkkkkkkkkkkkkkkkkkkkkk.
zzzzzzzzzzzzzzzzz.
dddddddddddddddddddd.
uuuuuuuuuuuuuuuuuuuuu.
aaaaaaaaaaaaaaaaaa. sedang, berat)
eeeeeeeeeeeeeeeeeeee.
vvvvvvvvvvvvvvvvvvvvv. S : Ibu klien nampak cemas
bbbbbbbbbbbbbbbbbb. rrrrrrrrrrrrrrrrrrrrrrr.Hasil : klien
ffffffffffffffffffff.
wwwwwwwwwwwwwwwwwwwww. dengan keadaan
cccccccccccccccccc. dalam kecemasan ringan (klien dapat
gggggggggggggggggggg.
xxxxxxxxxxxxxxxxxxxxx. penyakitnya.
dddddddddddddddddd.
hhhhhhhhhhhhhhhhhhhh.mengungkapkan kejadian masa lalu, llllllllllllllllllllllll.
yyyyyyyyyyyyyyyyyyyyy. O :
eeeeeeeeeeeeeeeeee.16 konsentrasi baik).
iiiiiiiiiiiiiiiiiiii. Ekspresi wajah nampak
ffffffffffffffffff.
jjjjjjjjjjjjjjjjjjjj.
2. Memberikan kesempatan ibu klien murung.
gggggggggggggggggg.
kkkkkkkkkkkkkkkkkkkk.
untuk mengungkapkan perasaannya mmmmmmmmmmmmmmmmmmmm
hhhhhhhhhhhhhhhhhh.
llllllllllllllllllll.
zzzzzzzzzzzzzzzzzzzzz.
(mendengarkan dengan baik pada saat A : Masalah belum teratasi.
iiiiiiiiiiiiiiiiii.
mmmmmmmmmmmmmmmmmmmm.
aaaaaaaaaaaaaaaaaaaaaa.
ibu klien bercerita). nnnnnnnnnnnnnnnnnnnnnnnn.
jjjjjjjjjjjjjjjjjj.
nnnnnnnnnnnnnnnnnnnn.
bbbbbbbbbbbbbbbbbbbbbb.
sssssssssssssssssssssss. Hasil: ibu P : Lanjutkan intervensi 1, 2, 3
Se oooooooooooooooooooo.
cccccccccccccccccccccc.
klien belum melakukannya. dan 4.
pppppppppppppppppppp.
dddddddddddddddddddddd. 1. Kaji tingkat kecemasan
3. Menjelaskan proses penyakit dan