COVER JUDUL

PANDUAN ASUHAN KEPERAWATAN (PAK)

DAN STANDART ASUHAN KEPERAWATAN (SAK)

RUMAH SAKIT MUHAMMADIYAH LAMONGAN

2019
 DAFTAR ISI

COVER JUDUL..........................................................................................................................i
DAFTAR ISI..............................................................................................................................ii
PANDUAN ASUHAN KEPERAWATAN MEDIK..................................................................1
1. CKD (CHRONIC KYDNEY DESEASE)......................................................................2
2. CVA (CEREBRO VASKULER ACCIDENT)...............................................................4
3. DEKOMPENSASI KORDIS..........................................................................................6
4. HIPERTENSI..................................................................................................................8
5. IMA (INFARK MIOKARD AKUT)............................................................................10
6. SIROSIS HEPATIS......................................................................................................12
7. SLE ( SISTEMIK LUPUS ERITEMATOSUS)...........................................................14
8. TB PARU......................................................................................................................16
9. PNEUMONIA...............................................................................................................18
10. EFUSI PLEURA...........................................................................................................20
PANDUAN ASUHAN KEPERAWATAN BEDAH...............................................................22
1. APPENDICITIS............................................................................................................23
2. BPH (BENIGN PROSTATIC HYPERPLASIA).........................................................25
3. CIDERA KEPALA.......................................................................................................27
4. DM GANGRENE.........................................................................................................29
5. FRAKTUR TERBUKA...............................................................................................32
6. FRAKTUR TERTUTUP...............................................................................................34
7. HYDRONEFROSIS......................................................................................................36
8. TUMOR KEPALA.......................................................................................................38
9. LBP...............................................................................................................................40
PANDUAN ASUHAN KEPERAWATAN ANAK DAN BAYI.............................................41
1. BRONCHOPNEUMONIA...........................................................................................42
2. DHF (DENGUE HEMORRAGIC FEVER).................................................................44
3. GASTROENTERITIS ACUT (GEA)...........................................................................46
4. FEBRIS CONVULSI....................................................................................................48
5. PHARINGITIS..............................................................................................................50
6. HYPERBILIRUBIN NEONATAL..............................................................................52
7. ASPHYXIA NEONATORUM.....................................................................................54
8. ACUTE RESPIRAOTRY DISTRESS SYNDROME (ARDS)....................................56
9. SEPSIS NEONATORUM.............................................................................................58
STANDART ASUHAN KEPERAWATAN...........................................................................60
1. ANSIETAS (D.0080)....................................................................................................61
1) REDUKSI ANXIETAS ( I.09314 ).......................................................................62
2) TERAPI RELAKSASI (I. 05186)..........................................................................63
2. BERSIHAN JALAN NAPAS TIDAK EFEKTIF (D.0001).........................................64
1) LATIHAN BATUK EFEKTIF (I.01006)..............................................................65
2) MENEJEMEN JALAN NAPAS (I. 01011)...........................................................66
3) PEMANTAUAN RESPIRASI (I.01014)...............................................................66
3. DEFISIT NUTRISI (D.0019).......................................................................................67
1) MENEJEMEN NUTRISI (I. 03119)......................................................................69
2) PROMOSI BERAT BADAN (I.03136).................................................................69
4. DEFISIT PERAWATAN DIRI (D.0109).....................................................................70
1) DUKUNGAN PERAWATAN DIRI (1.11348).....................................................71
5. DIARE (D.0020)...........................................................................................................72
1) MENEJEMEN DIARE (I.03101)..........................................................................73
ii
 2) PEMANTAUAN CAIRAN (I.03121)...................................................................74
6. GANGGUAN CITRA TUBUH (D.0083)....................................................................75
1) PROMOSI CITRA TUBUH ( I.09305).................................................................76
7. GANGGUAN ELIMINASI URINE (D.0040).............................................................77
1) MANAJEMEN ELIMINASI URINE....................................................................78
8. GANGGUAN INTEGRITAS KULIT/JARINGAN (D.0129).....................................79
1) PERAWATAN INTEGRITAS KULIT (I.11353).................................................80
2) PERAWATAN LUKA ( I.14564 )........................................................................81
9. GANGGUAN KOMUNIKASI VERBAL (D.0119)....................................................81
1) PROMOSI KOMUNIKASI: DEVISIT VISUAL (I.13494)..................................83
10. GANGGUAN MENELAN (D.0063)...........................................................................84
1) DUKUNGAN PERAWATAN DIRI: MAKAN/MINUM (1.11351)....................86
2) PENCEGAHAN ASPIRASI (I. 01018)................................................................86
11. GANGGUAN MOBILITAS FISIK (D.0054)..............................................................87
1) DUKUNGAN AMBULASI (1.06171)..................................................................88
2) DUKUNGAN MOBILISASI (I.05173).................................................................89
12. GANGGUAN PERSEPSI SENSORI (D.0085)............................................................89
1) MINIMALISASI RANGSANGAN (I.08241).......................................................91
13. GANGGUAN PERTUKARAN GAS (D. 0003)..........................................................92
1) PEMANTAUAN RESPIRASI (I.01014)...............................................................93
2) TERAPI OKSIGEN (I.01026)...............................................................................93
14. HIPOTERMIA (D.0131)..............................................................................................94
1) MANAJEMEN HIPOTERMIA (I.14507).............................................................96
2) TERAPI PAPARAN PANAS (I.14586)................................................................96
15. HIPERTERMIA (D.0130)............................................................................................96
1) MANAJEMEN HIPERTERMIA (I.15506)...........................................................98
2) REGULASI TEMPERATUR (I.14578)................................................................98
16. HIPERVOLEMIA (D.0022).........................................................................................99
1) MANAJEMEN HIPERVOLEMIA (I.03114)......................................................101
2) PEMANTAUAN CAIRAN (I.03121).................................................................101
17. HIPOVOLEMIA.........................................................................................................102
1) MANAJEMEN HIPOVOLEMIA (I.03116)........................................................104
2) PEMANTAUAN CAIRAN (I.03121).................................................................104
18. INTOLERANSI AKTIVITAS (D.0056)....................................................................105
1) MANAJEMEN ENERGI (I. 05178)....................................................................106
2) TERAPI AKTIVITAS (I.05186).........................................................................107
19. IKTERIK NEONATUS (D.0024)...............................................................................108
1) FISIOTERAPI NEONATUS (I.03091)...............................................................109
2) PERAWATAN BAYI (I.10338)..........................................................................110
20. KELETIHAN (D.0057)..............................................................................................110
1) EDUKASI AKTIVITAS/ISTIRAHAT (1.12362)...............................................112
2) MANAJEMEN ENERGI.....................................................................................112
21. KEPUTUSASAAN (D.0088).....................................................................................113
1) DUKUNGAN EMOSIONAL (1.09256).............................................................114
2) PROMOSI HARAPAN (I.09307)........................................................................114
22. KETIDAKSTABILAN KADAR GULA DARAH (D.0027)....................................115
1) MANAJEMEN HIPERGLIKEMIA (I.03115)....................................................116
2) MANAJEMEN HIPOGLIKEMIA (I.03113)......................................................117
23. NAUSEA (D.0076).....................................................................................................118
1) MENEJEMEN MUAL (I. 03117)........................................................................119
iii
 24. NYERI AKUT (D.0077).............................................................................................120
1) MENEJEMEN NYERI (I. 08238).......................................................................121
2) PEMBERIAN ANALGETIK (I.08243)..............................................................122
25. PENURUNAN CURAH JANTUNG (D.0008)..........................................................123
1) PERAWATAN JANTUNG (I.02075).................................................................125
2) PERAWATAN JANTUNG AKUT( I.02076).....................................................126
26. PENURUNAN KAPASITAS ADAPTIF INTRACRANIAL (D.0066).....................127
1) MENEJEMEN PENINGKATAN TEKANAN INTRAKRANIAL (I. 06198)...129
2) PEMANTAUAN TEKANAN INTRAKRANIAL (I.06198)..............................129
27. PERFUSI PERIFER TIDAK EFEKTIF (D.0009)......................................................130
1) PERAWATAN SIRKULASI (I.02079)...............................................................132
2) MANAJEMEN SENSASI PERIFER (I. 06195).................................................132
28. POLA NAPAS TIDAK EFEKTIF (D.0005)..............................................................133
1) PEMANTAUAN RESPIRASI (I.01014).............................................................134
2) MENEJEMEN JALAN NAPAS (I. 01011).........................................................135
29. RISIKO KETIDAKSEIMBANGAN CAIRAN (D.0036)..........................................136
1) MANAJEMEN CAIRAN (I.03098)....................................................................136
2) PEMANTAUAN CAIRAN (I.03121).................................................................137
30. RISIKO KETIDAKSEIMBANGAN ELEKTROLIT (D.0037).................................137
1) PEMANTAUAN ELEKTROLIT (I.03122)........................................................138
2) MANAJEMEN CAIRAN (I.03098)....................................................................139
31. NYERI KRONIS (D.0078).........................................................................................140
1) MENEJEMEN NYERI (I. 08238).......................................................................141
2) PERAWATAN KENYAMANAN (I.08245)......................................................142
32. RISIKO ASPIRASI (D.0006).....................................................................................143
1) MENEJEMEN JALAN NAPAS (I. 01011).........................................................144
2) PENCEGAHAN ASPIRASI (I.01018)................................................................144
33. RISIKO JATUH (D.0143)..........................................................................................145
1) PENCEGAHAN JATUH (I. 14540)....................................................................146
34. RISIKO INFEKSI (D. 0142)......................................................................................146
1) PENCEGAHAN INFEKSI (I.14539)..................................................................148
2) MANAJEMEN IMUNISASI/ VAKSIN (I. 14508).............................................148
35. RESIKO PERFUSI SEREBRAL TIDAK EFEKTIF.................................................149
1) MENEJEMEN PENINGKATAN TEKANAN INTRAKRANIAL (I. 06198)...150
2) PEMANTAUAN TEKANAN INTRAKRANIAL (I.06198)..............................151
36. RISIKO PERFUSI MIOKARD TIDAK EFEKTIF....................................................152
1) MANAJEMEN ARITMIA (1.02035)..................................................................153
2) MENEJEMEN SYOK KARDIOGENIK (I. 02051)............................................154
37. RISIKO PERFUSI PERIFER TIDAK EFEKTIF.......................................................154
1) PENCEGAHAN SYOK (I.14545)......................................................................155
2) PERAWATAN SIRKULASI (I.02079)...............................................................156
38. RISIKO PERFUSI RENAL TIDAK EFEKTIF..........................................................157
1) PENCEGAHAN SYOK (I.14545)......................................................................158
2) PENCEGAHAN PENDARAHAN (I. 02067).....................................................159
39. RISIKO PERLAMBATAN PEMULIHAN PASCABEDAH....................................159
1) DUKUNGAN MOBILISASI (I.05173)...............................................................160
2) MENEJEMEN NUTRISI (I. 03119)....................................................................161
DAFTAR PUSTAKA.............................................................................................................162

iv
PANDUAN ASUHAN KEPERAWATAN

MEDIK

5
1. CKD (CHRONIC KYDNEY DESEASE)

PANDUAN ASUHAN KEPERAWATAN (PAK)

CKD (CHRONIC KYDNEY DESEASE)

1 Pengertian Asuhan keperawatan pada pasien dengan Chronic kidney
desease
2 Assesmen Keperawatan 1. Mual
2. Muntah
3. Sesak
4. Mudah lelah
5. Pucat
6. Kurangnya produksi urine.
7. Gatal- gatal
8. Oedema
9. Pengkajian Biologi,Psikologis, sosial, Spiritual
3 Diagnosis Keperawatan 1. Hypervolemia (D.0022)
2. Info (D.0009)
3. Gangguan pertukaran gas (D.0003)
4. Nausea (D.0076)
5. Risiko perfusi renal tidak efektif (D.0016)
6. Risiko ketidakseimbangan elektrolit (D.0037)
7. Defisit nutrisi (D.0019)
8. Gangguan integritas kulit atau jaringan (D.0129)
9. Intoleransi aktivitas (D.0056)
4 Kriteria Evaluasi/ 1. Keseimbangan cairan meingkat (L.03021)
Nursing Outcome 2. Perfusi perifer meningkat (L.02011)
3. Pertukaran gas meningkat (L.01002)
4. Tingkat nausea menurun (L.08065)
5. Perfusi renal meningkat (L.02013)
6. Status nutrisi membaik (L.06053)
7. Keseimbangan elektrolit meningkat (L.03021)
8. Status nutisi membaik (L.03030)
9. Integritas dan jaringan kulit meningkat (L.14125)
10. Toleransi aktifitas meningkat (L.05047)
5 Intervensi Keperawatan 1. Manajemen hypervolemia(I.03114)
2. Pemantauan cairan (I.03121)
3. Perawatan sirkulasi (I.02079)
4. Manejemen sensasi perifer (I.06195)
5. Pemantauan respirasi (I.01014)
6. Terapi oksigen (I.01026)
7. Manajemen mual (I.03117)

6
 8. Manajemen energy (I.05178)
9. Pencegahan syok (I.02068)
10. Pemantauan elektrolit (I.03122)
11. Manajemen elektrolit hyperkalemia (I.03103)
12. Manajemen nutrisi (I.03119)
13. Promosi Berat badan (I.03136)
14. Terapi relaksasi (I.09326)
15. Perawatan integritas kulit (I.11353)
16. Dukungan mobilisasi (I.05173)
6 Informasi dan Edukasi 1. Ajarkan cara membatasi cairan
2. Anjurkan melapor bila haluran urin <0.5 ml/kg/jam
dalam 6 jam dan bila BB bertambah >1 kg dalam sehari
3. Tujuan dan prosedur ambulasi dan mobilisasi
7 Evaluasi Mengevaluasi respon subyektif dan obyektif setelah
dilaksanakan intervensi dan dibandingkan dengan outcome
serta analisis terhadap perkembangan diagnosis
8 Penelaah Kritis Sub Komite Mutu Keperawatan
9 Kepustakaan 1. Herdman, T.H. & Kamitsuru, S. (Eds). (2014). NANDA
international Nursing Diagnoses: Definitions &
classification, 2015-2017. Oxford : Wiley Blackwell.
2. Lewis, SL., Dirksen, SR., Heitkemper, MM, and
Bucher, L.(2014).Medical surgical Nursing. Mosby:
ELSIVER
3. Tim Pokja SDKI DPP PPNI, (2016), Standar Diagnosis
Keperawatan Indonesia (SDKI), Edisi 1, Jakarta,
Persatuan Perawat Indonesia
4. Tim Pokja SLKI DPP PPNI, (2018), Standar Luaran
Keperawatan Indonesia (SLKI), Edisi 1, Jakarta,
Persatuan Perawat Indonesia
5. Tim Pokja SIKI DPP PPNI, (2018), Standar Intervensi
Keperawatan Indonesia (SIKI), Edisi 1, Jakarta,
Persatuan Perawat Indonesia

7
8
 STANDART
ASUHAN KEPERAWATAN

9
1. HIPERVOLEMIA (D.0022)
1. DEFINISI
Peningkatan cairan intravascular, intertisial, dan/atau intraseluler

2. PENYEBAB
 Gangguan mekanisme regulasi
 Kelebihan asupan cairan
 Kelebihan asupan natrium
 Gangguan aliran balik vena
 Efek agen farmakologis (mis. kortikostreroid, chlorpropamide, tolbutamide,
vincristione, tryptilinescarbamazepine)

3. GEJALA MAYOR
Subyektif Obyektif
 Ortopnea  Edema anasarka dan/atau edema
 Dispnea perifer
 Paroxysmal nocturnal dyspnea  Berat badan meningkat dalam waktu
(PND) singkat
 Jugular Venous Pressure (JVP)
dan/atau Central Venous Pressure
(CVP) meningkat
 Refleks hepatojugular positif

4. GEJALA MINOR
Subyektif Obyektif
 (tidak tersedia)  Distensi vena jugularis
 Terdengar suara napas tambahan
 Hepatomegali
 Kadar Hb/Ht turun
 Oliguria
 Intake lebih banyak dari output
(balans cairan positif)
 Kongesti paru

5. KONDISI KLINIS
 Penyakit ginjal: gagal ginjal akut/kronis, sindrom nefrotik
 Hipoalbuminemia
 Gagal jantung kongestif
 Kelainan hormone
 Penyakit hati (mis. sirosis, asites, kanker hati)
 Penyakit vena perifer (mis. varises vena, thrombus vena, phlebitis)
6. OUTCOME
1) Keseimbangan cairan L.03020
Definisi

10
 Ekuilibrium antara colume cairan di ruang intra seluler dan ekstraseluler tubuh
Ekspektasi : Meningkat
2) Kriteria Hasil
Asupan cairan Meningkat
Output urine Meningkat
Membrane mukosa lembap Meningkat
Asupan makanan Meningkat

Edema Menurun
Dehidrasi Menurun
Asites Menurun
Konfusi Menurun

Tekanan darah Membaik

Frekwensi Nadi Membaik
Kekuatahn Nadi Membaik
Tekanan arteri rata rata Membaik
Mata cekung Membaik
Turgor kulit Membaik
Berat badan Membaik

3) INTERVENSI KEPERAWATAN
1) MANAJEMEN HIPERVOLEMIA (I.03114)
a) Definisi
Mengidentifikasi dan mengelola kelebihan volume cairan intravaskuler dan
ekstraseluler serta mencegah terjadinya komplikasi
b) Tindakan
1. Observasi
 Periksa tanda dan gejala hypervolemia
 Identifikasi penyebab hypervolemia
 Monitor status hemodinamik, tekanan darah, MAP, CVP, PAP, PCWP,
CO jika tersedia
 Monitor intaje dan output cairan
 Monitor tanda hemokonsentrasi ( kadar Natrium, BUN, hematocrit,
berat jenis urine)
 Monitor tanda peningkatan tekanan onkotik plasma
 Monitor kecepatan infus secara ketat
 Monitor efek samping diuretik
2. Therapeutik
 Timbang berat bada setiap hari pada waktu yang sama
 Batasi asupan cairan dan garam
 Tinggikan kepala tempat tidur 30-40 derajat
3. Edukasi
 Anjurkan melapor jika haluaran urine <0.5 ml/kg/jam dalam 6 jam
 Anjurkan melapor jika BB bertambah > 1 kg dalam sehari
 Ajarkan cara mengukur dan mencatat asupan dan haluaran cairan
 Ajarkan cara membatasi cairan
4. Kolaborasi
11
  Kolaborasi pemberian diuritik
 Kolaborasi penggantian kehilangan kalium akibat diuretic
 Kolaborasi pemberian continuous renal replacement therapy

2) PEMANTAUAN CAIRAN (I.03121)

a) Definisi
Mengumpulkan dan menganalisis data terkait pengaturan keseimbangan
cairan
b) Tindakan
1. Observasi
 Monitor frekuensi dan kekuatan nadi
 Monitor frekuensi nafas
 Monitor tekanan darah
 Monitor berat badan
 Monitor waktu pengisian kapiler
 Monitor elastisitas atau turgor kulit
 Monitor jumlah, waktu dan berat jenis urine
 Monitor kadar albumin dan protein total
 Monitor hasil pemeriksaan serum (mis. Osmolaritas serum, hematocrit,
natrium, kalium, BUN)
 Identifikasi tanda-tanda hipovolemia (mis. Frekuensi nadi meningkat,
nadi teraba lemah, tekanan darah menurun, tekanan nadi menyempit,
turgor kulit menurun, membrane mukosa kering, volume urine
menurun, hematocrit meningkat, haus, lemah, konsentrasi urine
meningkat, berat badan menurun dalam waktu singkat)
 Identifikasi tanda-tanda hypervolemia 9mis. Dyspnea, edema perifer,
edema anasarka, JVP meningkat, CVP meningkat, refleks
hepatojogular positif, berat badan menurun dalam waktu singkat)
 Identifikasi factor resiko ketidakseimbangan cairan (mis. Prosedur
pembedahan mayor, trauma/perdarahan, luka bakar, apheresis,
obstruksi intestinal, peradangan pankreas, penyakit ginjal dan kelenjar,
disfungsi intestinal)
2. Terapeutik
 Atur interval waktu pemantauan sesuai dengan kondisi pasien
 Dokumentasi hasil pemantauan
3. Edukasi
 Jelaskan tujuan dan prosedur pemantauan
 Informasikan hasil pemantauan, jika perlu

12
 DAFTAR PUSTAKA

Herdman, T.H. & Kamitsuru, S. (Eds). (2014). NANDA international Nursing Diagnoses:
Definitions & classification, 2015-2017. Oxford : Wiley Blackwell.
Lewis, SL., Dirksen, SR., Heitkemper, MM, and Bucher, L.(2014).Medical surgical Nursing.
Mosby: ELSIVER
Tim Pokja SDKI DPP PPNI, (2016), Standar Diagnosis Keperawatan Indonesia (SDKI),
Edisi 1, Jakarta, Persatuan Perawat Indonesia
Tim Pokja SLKI DPP PPNI, (2018), Standar Luaran Keperawatan Indonesia (SLKI), Edisi 1,
Jakarta, Persatuan Perawat Indonesia
Tim Pokja SIKI DPP PPNI, (2018), Standar Intervensi Keperawatan Indonesia (SIKI), Edisi
1, Jakarta, Persatuan Perawat Indonesia

13