LAPORAN ASUHAN KEPERAWATAN

PADA PASIEN TN. DP DENGAN PPOK EXCASERBASI ACUT

DI RUANG NAKULA, RSUD SANJIWANI GIANYAR

PADA TANGGAL 30-7-2018 S/D 2-8-2018

OLEH :

NAMA : NI MADE SURYATI

NIM : 18.901.1972

KELOMPOK : 12

PROGRAM STUDI PROFESI NERS

STIKES WIRA MEDIKA PPNI BALI

DENPASAR

2017
 ASUHAN KEPERAWATAN PADA TN. DP DENGAN PPOK EXCASERBASI ACUT
DI RUANG NAKULA RSUD SANJIWANI GIANYAR
PADA TANGGAL 30-7-2018 S/D 2-8-2018

A. PENGKAJIAN
1. Data Umum
a. Identitas Klien
Nama : Tn. DP
Umur : 58 Tahun
Agama : Hindu
Jenis Kelamin : Laki-laki
Status Marital : Menikah
Pendidikan : Tidak tamat SD
Pekerjaan : Pekerja bangunan
Suku Bangsa : Bali
Alamat : Br. Pegesangan, Desa Temesi, Gianyar
Tanggal Masuk : 29-07-2018
Tanggal Pengkajian : 30-7-2018
No. Register : 628514
Diagnosa Medis : PPOK Excaserbasi Acut
b. Identitas Penanggung Jawab
Nama : Tn. DA
Umur : 34 Tahun
Hub. Dengan Klien : Anak
Pekerjaan : Wiraswasta
Alamat : Br. Pegesangan, Desa Temesi, Gianyar

2. Riwayat Kesehatan
a. Status Kesehtan Saat Ini
Keluhan Utama
Saat MRS : Sesak
Saat Pengkajian : Sesak

b. Riwayat Penyakit Sekarang

1) Alasan masuk rumah sakit dan perjalanan saat ini
Pasien mengalami batuk-batuk sejak 2 minggu yang lalu, batuk berdahak dan agak
sulit untuk dikeluarkan. Sejak 3 hari yang lalu, pasien mengeluh sesak, sesak
bertambah berat sejak kemarin pagi, nafas dirasakan berat saat menarik dan
mengeluarkan nafas, keluhan disertai juga dengan panas badan. Oleh karena itu pasien
dibawa berobat ke Unit Gawat Darurat (UGD ) RSUD Sanjiwani Gianyar.
2) Upaya yang dilakukan untuk mengatasinya
Pasien sudah berobat ke Puskesmas sebanyak 2 kali, karena keluhannya tidak
berkurang, pasien sudah dibawa berobat ke Dokter Swasta.
 c. Riwayat Kesehatan Dahulu
1) Penyakit yang pernah dialami
Pasien sejak umur sekitar 40 tahun sering mengalami batuk-batuk, tetapi biasanya
setelah di bawa berobat ke Puskesmas, keluhan tersebut mau berkurang. Pasien tidak
pernah mengalami penyakit kronis lainnya.
2) Pernah dirawat
Pasien sebelumnya tidak pernah menjalani rawat inap.
3) Alergi
Pasien tidak mempunyai riwayat alergi, baik alergi obat maupun alergi makanan.
4) Kebiasaan
Pasien mempunyai kebiasaan minum kopi 2-3 kali setiap hari. Pasien juga mempunyai
kebiasaan merokok sejak pasien masih muda, pasien biasa merokok ½ sampai 1
bungkus per hari. Dulu saat masih muda pasien sering minum minuman keras, tetapi
setelah menikah kebiasaan tersebut sangat jarang dilakukan. Pasien sebelumnya
bekerja sebagai pekerja bangunan, dan sering memotong kayu atau keramik
menggunakan mesin pemotong, sering kali saat melakukan pekerjaan tersebut pasien
tidak menggunakan masker.

d. Riwayat Kesehatan Keluarga

Ayah pasien dulu mengalami penyakit yang sama dengan pasien, mengalami batuk-
batuk dan sesak, tidak ada batuk dengan dahak berdarah, tetapi dulu hanya dirawat di
rumah saja dan sudah meninggal. Istri pasien mempunyai riwayat penyakit hipertensi
dan biasa berobat ke Puskesmas, riwayat penyakit lainnya tidak ada. Anggota keluarga
yang lain (anak, menantu, dan cucu-cucunya) tidak ada yang mempunyai riwayat
penyakit kronis maupun penyakit batuk lama dan menjalani pengobatan selama 6
bulan.

e. Riwayat Sosiokultural
Pasien mengatakan tidak mengalami masalah dalam berhubungan dengan orang lain
dilingkungannya, dan tidak ada masalah budaya pasien yang bertentangan dengan
kesehatan.

3. Pola Fungsi Kesehatan Gordon

a. Pola Persepsi dan Manajemen Kesehatan
Pasien dan keluarga memiliki persepsi yang baik terhadap kesehatan, keluarga
beranggapan bahwa kesehatan adalah suatu hal yang penting dan harus dijaga. Apabila
ada anggota keluarga yang sakit, biasanya dibawa berobat ke Puskesma atau Dokter
swasta.

b. Pola Nutrisi-Metabolik
 Sebelum sakit
Pasien mengatakan sebelum sakit biasanya makan 3-4 kali per hari, setiap makan
habis ½-1 porsi, dengan komposisi nasi, lauk, sayur dan buah. Pasien biasa minum 6-7
gelas per hari dengan jumlah sekitar 1500 cc.
 Saat sakit
Sejak sakit nafsu makan pasien agak berkurang, tetapi pasien tetap memaksakan untuk
makan. Selama pasien dirawat, nafsu makannya agak berkurang, karena sesak yang
dialami. Pasien makan 3 kali setiap hari setiap makan habis ½-1 porsi, dengan
komposisi nasi, lauk, sayur dan buah, yang disediakan di rumah sakit. BB = 55 kg, TB
= 165 cm, lingkar lengan atas = 25 cm. hasil lab HB = 11,0 gr/dl, HCT = 38,3 %.
 Selama pasien dirawat, pasien tidak mengalami penurunan berat badan, rambut kuning
tidak ada. Pasien mendapatkan diet BB TKTP, lingkungan pasien mendukung pasien
untuk memenuhi kebutuhan nutrisinya. Pasien masih mengalami kelemahan sehingga
kebutuhan aktifitasnya harus dibantu oleh keluarga atau Perawat.

c. Pola Eleminasi
1) BAK
 Sebelum sakit
Pasien mengatakan sebelum sakit biasa buang air kecil (BAK) 4-5 kali setiap hari,
dengan jumlah sekitar 1 gelas (200 cc) setiap kali BAK.
 Saat sakit
Pasien mengatakan selama sakit tidak mengalami perubahan dalam BAK, buang air
kecil (BAK) 4-5 kali setiap hari, dengan jumlah sekitar 1 gelas (200 cc) setiap kali
BAK.
2) BAB
 Sebelum sakit
Pasien mengatakan sebelum sakit biasa buang air besar (BAB) 1 kali setiap hari,
dengan jumlah sekitar 200 cc setiap kali BAB.
 Saat sakit
Pasien mengatakan selama sakit tidak mengalami perubahan dalam BAB, buang air
besar (BAB) 1 kali setiap hari, dengan jumlah sekitar 200 cc setiap kali BAB.

d. Pola Aktivitas dan Latihan

1) Oksigenasi
 Sebelum sakit
Pasien mengatakan sebelum sakit tidak mengalami batuk maupun hambatan saat
bernafas.
 Saat sakit
Pasien mengeluh batuk dan sesak, nafas dirasakan berat saat menarik dan
mengeluarkan nafas, sesak dirasakan memberat saat pasien beraktifitas. Pasien tampak
sesak, dan sering batuk, saat tidur pasien juga tampak sesak. Pasien mengatakan
batuknya timbul dengan waktu yang tidak menentu. Dahak pasien cukup banyak,
berwarna putih kehijauan, darah tidak ada.

2) Aktifitas
Kemampuanperawatandiri 0 1 2 3 4
Makan / minum V
Mandi V
Toileting V
Berpakaian V
Mobilisasi di tempat tidur V
Berpindah V
Ambulasi ROM V
Ket :
0: mandiri, 1: alat Bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4: tergantung total

3) Latihan
 Sebelum sakit
Pasien mengatakan sebelum sakit tidak mengalami hambatan dalam bergerak dan
beraktifitas sebagai pekerja bangunan.
 Saat sakit
Pasien mengatakan selama sakit tidak bisa beraktifitas seperti biasa karena pasien
mengalami sesak, sesak dirasakan memberat saat pasien beraktifitas. Pasien
mengalami kelemahan sehingga kebutuhan aktifitasnya harus dibantu oleh keluarga
atau Perawat, setelah melakukan aktifitas berpindah dari tempat tidur, pasien tampak
sesaknya bertambah, frekuensi respirasi dan nadi meningkat. Pasien hanya mampu
melakukan gerak di tempat tidur

e. Pola koqnitif dan Persepsi sensori

 Pola koqntif
Pasien dan keluarga mengatakan belum mengetahui tentang perawatan pasien dengan
penyakit PPOK, apa yang bisa dilakukan pasien dengan mandiri. Keluarga
menanyakan tentang pencegahan kekambuhan dan upaya pencegahan terjadinya
PPOK pada anggota keluarga yang lain. Pasien tidak mampu menjawab pertanyaan
petugas saat ditanyakan tentang upaya yang bisa dilakukan pasien dengan mandiri
dalam perawatan penyakitnya.
 Pola persepsi sensori
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f. Pola Persepsi-Konsep diri
 Gambaran diri/ citra diri
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 Ideal diri
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 Harga diri
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 Peran
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 Identitas
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g. Pola Tidur dan Istirahat
 Sebelum sakit
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 Saat sakit
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h. Pola Peran-Hubungan
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i. Pola Seksual-Reproduksi
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j. Pola Toleransi Stress-Koping
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k. Pola Nilai-Kepercayaan
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4. PEMERIKSAAN FISIK
a. Keadaan Umum :.......................................................................................
Tingkat kesadaran : (Composmetris/ Apatis/ Somnolen/ Supor/ Coma)
Glasgow Coma Scale : ..................................................................................................
b. Tanda Vital
S : ...................... TD : ...................... N : ........................ RR : ........................
c. Kepala
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d. Mata
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e. Hidung
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f. Telinga
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g. Mulut
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h. Leher
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i. Dada dan Punggung
1) Thoraks
Inspeksi : .................................................................................................................
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Palpasi : .................................................................................................................
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Perkusi : .................................................................................................................
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Auskultas : .................................................................................................................
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2) Jantung
Inspeksi : .................................................................................................................
Palpasi : .................................................................................................................
Perkusi : .................................................................................................................
Auskultas : .................................................................................................................
3) Payudara
Inspeksi : .................................................................................................................
Palpasi : .................................................................................................................
j. Abdomen
Inspeksi : .................................................................................................................
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Auskultasi : .................................................................................................................
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Palpasi : .................................................................................................................
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perkusi : .................................................................................................................
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k. Ekstremitas
Atas
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Bawah
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l. Genetalia& Anus
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5. DATA PENUNJANG
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6. DATA TAMBAHAN
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TERAPHY :

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