ANALISA DATA

Nama Pasien : An. K Ruang : PICU

Umur : 4 Tahun Hari/tgl : 9 April 2019
No Data Fokus Etiologi Problem/Masalah
DS : Ibu px mengatakan px panas hari ke Trombositopeni Resiko syok
5, gusi berdarah dan sempat mimisan. ↓ hipovolemik b.d
Perdarahan hipoksia jaringan
DO : K/U Lemah ↓
GCS 4-5-6 Compos Mentis Resiko perfusi jaringan
S: 37,8 tidak efektif
N : 92 ↓
RR : 30 Hipoksia jaringan
TD : 117/72 ↓
- Px tampak merengek Asidosis metabolic
- Akral dingin ↓
- Hb : 11,1 Resiko syok
- HCT : 32,2

PRIORITAS MASALAH
1. Resiko syok berhubungan dengan hipoksia jaringan
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RENCANA KEPERAWATAN
Nama Pasien : An. K Ruang : PICU
Umur : 4 Tahun Hari/tgl : 9 April 2019
Diagnosa Tujuan (NOC) Intervensi (NIC)
Resiko syok ( hipovolemik ) - Syok prevention 1. Observasi TTV
b.d hipoksia jaringan - Syok manajement 2. Monitor tanda
Kriteria hasil : inadekuat oksigenasi
- Ttv dalam rentang jaringan
normal 3. Pantau nilai HB,HT
TD : 95 – 107 / 60 -70 4. Monitor tanda gejala
S: 36,5 – 37,5 syok
N : 65 – 110 5. Posisikan px dalam
RR : 20 – 25 posisi supine
- 6. Berikan terapi sesuai
perintah dokter
CATATAN PERKEMBANGAN
Diagnosa Keperawatan: Resiko syok ( hipovolemik ) berhubungan dengan hipoksia jaringan
Hari/Tgl/Jam Implementasi Paraf Evaluasi (SOAP)
1. Mengobservasi TTV S : Ibu px mengatakan panas mulai turun, tidak ada
9 april 2019 S : 37,8 perdarahan digusi dan tidak mimisan
N: 92
RR : 30 O : K/U Cukup
TD : 119/72 S: 36,8
2. Memonitor tanda inadekuat oksigenasi jaringan N : 95
3. Memantau nilai HB, HCT RR : 25
HB : 11,1 TD :100 / 70
HCT : 32,2 A : Resiko Syok
4. Memberikan px posisi supine P : Intervensi di lanjutkan
5. Memberikan terapi sesuai perintah dokter - Observasi ttv
Inf. D5 ½ 1150 cc/ 24 jam - Monitor tanda inadekuat oksigenasi
Inj. Dexametaxon 1/5 amp jaringan
Inj. Pamol 150 mg - Pantau nilai HB, HCT
Inj. Ranitidine 1/5 amp - Berikan terapi sesuai perintah dokter