LAPORAN PENDAHULUAN ASUHAN

KEPERAWATAN SUBDURAL HEMATOMA

OLEH
I MADE SUMAHARIANTA RADIN
PO7120012083

Kementerian Kesehatan RI P!

ite"ni" Kesehatan
Den#asar 201$
 LAPORAN PENDAHULUAN SU%DURAL HEMATOMA
I& KONSEP
DASAR A&
PEN'ERTIAN
Hematma s()*(ra! a*a!ah #en+(m#(!an *arah *iantara *(ra *an *asar ta",
s(at( r(an+ ini #a*a "ea*aan nrma! *iisi !eh -airan& Pa!in+ serin+ *ise)a)"an !eh
tra(ma, teta#i *a#at .(+a ter.a*i "e-en*er(n+an #er*arahan /an+ seri(s
*an ane(risma& Hematma s()*(ra! !e)ih serin+ ter.a*i #a*a ena *an mer(#a"an
a"i)at
 #(t(sn/a #em)(!(h *arah "e-i! /an+ men.em)atani r(an+ s()*(ra!&
Per*arahan s()*(ra! a*a!ah #er*arahan "arena tra(ma /an+ ter.a*i
antara mem)ran !(ar *an menen+ah menin+es /an+ me!i#(ti ta"& Hematma
s()*(ra!
*ise)a)"an "arena r)e"an #erm("aan ena ata( #en+e!(aran "(m#(!an *arah
ena& Hematma s()*(ra! *a!am )ent(" "rni", han/a *arah /an+ e(si "e r(an+
s()*(ra! a"i)at #e-ahn/a ena4ena #en+h()(n+, (m(mn/a *ise)a)"an !eh -
e*era "e#a!a tert(t(#& E(si it( mer(#a"an #rses )ertaha# /an+ men/e)a)"an
)e)era#a min++( sete!ah -e*era, sa"it "e#a!a *an tan*a4tan*a "a! #r+resi /an+
men(n.(""an !"asi
+(m#a!an *arah&
5a*i s()*(ra! hematm a*a!ah #er*arahan *iantara !a#isan *(rameter *an !a#isan
ara"ni* /an+ *ia"i)at"an !eh tra(ma *imana ter.a*i r)e"an #erm("aan ena ata(
 #en+e!(aran "(m#(!an *arah ena&

%& PATO6ISIOLO'I
Per*arahan ter.a*i antara *(ramater *an ara"hni*ea& Per*arahan *a#at
ter.a*i a"i)at r)e"n/a ena .em)atan )ri*+in+ eins /an+ men+h()
(n+"an ena *i
 #erm("aan ta" *an sin(s ens(s *i *a!am *(ramater ata( "arena
r)e"n/a ara"ni*ea& Karena ta" /an+ )erman*i"an -airan -ere)rs#ina!
*a#at )er+era", se*an+"an sin(s ens(s *a!am "ea*aan teri"sir,
)er#in*ahn/a #sisi ta" /an+ ter.a*i #a*a tra(ma, *a#at mer)e" )e)era#a ena
ha!(s #a*a tem#at *i mana mere"a menem)(s *(ramater Per*arahan /an+ )esar
a"an menim)(!"an +e.a!a4+e.a!a a"(t men/er(#ai hematma e#i*(ra!&
Per*arahan /an+ ti*a" ter!a!( )esar a"an mem)e"( *an *i se"itarn/a a"an t(m)(h
 .arin+an i"at /an+ mem)ent(" "a#s(!a& '(m#a!an *arah !am)at !a(n men-
air *an menari" -airan *ari se"itarn/a *an men+em)(n+ mem)eri"an +e.a!a
se#erti t(mr sere)ri "arena te"anan intra-rania! /an+ )eran+s(r menin+"at&
Per*arahan s() *(ra! "rni" (m(mn/a )erassiasi *en+an atri sere)ra!& ena
 .em)atan *ian++a# *a!am te"anan /an+ !e)ih )esar, )i!a !(me ta"
men+e-i! sehin++a a!a(#(n han/a tra(ma /an+ "e-i! sa.a *a#at men/e)a)"an
r)e"an #a*a
ena terse)(t& Per*arahan ter.a*i se-ara #er!ahan "arena te"anan sistem ena /an+
ren*ah, serin+ men/e)a)"an ter)ent("n/a hematma /an+ )esar se)e!(m
+e.a!a "!inis m(n-(!& Pa*a #er*arahan s()*(ra! /an+ "e-i! serin+ ter.a*i
#er*arahan /an+ s#ntan& Pa*a hematma /an+ )esar )iasan/a
men/e)a)"an ter.a*in/a mem)ran
 as"(!ar /an+ mem)(n+"(s hematma s()*(ra! terse)(t& Per*arahan )er(!an+ *ari
 #em)(!(h *arah *i *a!am mem)ran ini meme+an+ #eranan #entin+, "arena #em)(!(h
*arah #a*a mem)ran ini .a(h !e)ih ra#(h sehin++a *a#at )er#eran *a!
am
 #enam)ahan !(me *ari #er*arahan s()*(ra! "rni"&
A"i)at *ari #er*arahan s()*(ra!, *a#at menin+"at"an te"anan intra"rania! *an
 #er()ahan *ari )ent(" ta"& Nai"n/a te"anan intra "rania! *i"m#ensasi !eh e!("s
*ari -airan !i"(r "e a9is s#ina! *an *i"m#resi !eh sistem ena& Pa*a ase ini
 #enin+"atan te"anan intra "rania! ter.a*i re!ati #er!ahan "arena "m#!ains
te"anan intra "rania! /an+ -("(# tin++i&
Mes"i#(n *emi"ian #em)esaran hematma sam#ai #a*a s(at( titi" tertent( a"an
me!am#a(i me"anisme "m#ensasi terse)(t& Km#!ains intra"rania! m(!ai )er"(ran+
/an+ men/e)a)"an ter.a*in/a #enin+"atan te"anan intra "rania! /an+ -("(# )esar&
A"i)atn/a #er(si sere)ra! )er"(ran+ *an ter.a*i is"emi sere)ra!& Le)ih !an.(t *a#at
ter.a*i herniasi transtentria! ata( s()a!"sin& Herniasi tnsi!ar me!a!(i
ramen ma+n(m *a#at ter.a*i .i"a se!(r(h )atan+ ta" ter*rn+ "e )aah me!a!
(i in-is(ra tentria! !eh menin+"atn/a te"anan s(#ra tentria!& 5(+a #a*a
hematma s()*(ra! "rni", *i*a#at"an )aha a!iran *arah "e tha!am(s *an
+an+!ia )asaa!is !e)ih ter+an++( *i)an*in+"an *en+an *aerah ta" /an+ !ainn/a&
Ter*a#at 2 teri /an+ men.e!as"an ter.a*in/a #er*arahan s()*(ra! "rni", /ait(
teri *ari 'ar*ner /an+ men+ata"an )aha se)a+ian *ari )e"(an *arah a"an men-
air sehin++a a"an menin+"at"an "an*(n+an #rtein /an+ ter*a#at *i *a!am "a#s(!
*ari s()*(ra! hematma *an a"an men/e)a)"an #enin+"atan te"anan n"ti"
*i*a!am "a#s(! s()*(ra! hematma& Karena te"anan n"ti" /an+
menin+"at ini!ah /an+ men+a"i)at"an #em)esaran *ari #er*arahan
terse)(t& Teta#i tern/ata a*a "ntrersia! *ari teri 'ar*ner ini, /ait(
tern/ata *ari #ene!itian *i*a#at"an )aha te"anan n"ti" *i *a!am s()*(ra!
"rni" tern/ata hasi!n/a nrma! /an+ men+i"(ti han-(rn/a se! *arah merah&
Teri /an+ "e *(a men+ata"an )aha, #er*arahan
 )er(!an+ /an+ *a#at men+a"i)at"an ter.a*in/a #er*arahan s()*(ra! "rni",
a"tr an+i+enesis .(+a *item("an *a#at menin+"at"an ter.a*in/a #er*arahan
s()*(ra! "rni", "arena t(r(t mem)eri )ant(an *a!am #em)ent("an
#enin+"atan as"(!arisasi
*i !(ar mem)ran ata( "a#s(! *ari s()*(ra! hematma& Lee! *ari "a+(!asi, !ee!
a)nrma!itas en:im i)rin!iti" *an #enin+"atan a"tiitas *ari i)rin!iti"
*a#at men/e)a)"an ter.a*in/a #er*arahan s()*(ra! "rni"&

;& TANDA DAN 'E5ALA

1& Hematma S()*(ra! A"(t
Hematma s()*(ra! a"(t menim)(!"an +e.a!a ne(r!+i" *a!am 2$ sam#ai $8
 .am sete!ah -e*era& Dan )er"aitan erat *en+an tra(ma ta" )erat& 'an+
+(an ne(r!+i" #r+resi *ise)a)"an !eh te"anan #a*a .arin+an ta"
*an herniasi
 )atan+ ta" *a!am ramen ma+n(m, /an+ se!an.(tn/a menim)(!"an te"anan
  #a*a )atan+ ta"& Kea*an ini *en+an -e#at menim)(!"an )erhentin/a #erna#asan
*an hi!an+n/a "ntr! atas *en/(t na*i *an te"anan *arah&
2& Hematma S()*(ra! S()a"(t
Hematma ini men/e)a)"an *eisit ne(r!+i" *a!am a"t( !e)ih *ari $8 .am
teta#i "(ran+ *ari 2 min++( sete!ah -e*era& Se#erti #a*a hematma s()*(ra! a"(t,
hematma ini .(+a *ise)a)"an !eh #er*arahan ena *a!am r(an+an s()*(ra!&
Anamnesis "!inis *ari #enm*erita hematma ini a*a!ah a*an/a tra(ma "e#a!a
/an+ men/e)a)"an "eti*a"sa*aran, se!an.(tn/a *ii"(ti #er)ai"an
stat(s ne(r!+i" /an+ #er!ahan4!ahan& Nam(n .an+"a a"t( tertent(
#en*erita mem#er!ihat"an tan*a4tan*a stat(s ne(r!+i" /an+ mem)
(r("& Tin+"at "esa*aran m(!ai men(r(n #er!ahan4!ahan *a!am
)e)era#a .am&Den+an menin+"atn/a te"anan intra"rania! seirin+
#em)esaran hematma, #en*erita men+a!ami "es(!itan (nt(" teta# sa*ar *an
ti*a" mem)eri"an res#n terha*a# ran+san+an )i-ara ma(#(n n/eri&
Per+eseran isi intra-rania! *an #enin+"atan intra-rania! /an+ *ise)a)"an !
eh a"(m(!asi *arah a"an menim)(!"an herniasi (n"(s ata( sentra! *an me!
en+"a#i tan*a4tan*a ne(r!+i" *ari "m#resi )atan+
ta"&
3& Hematma S()*(ra! Krni" 
Tim)(!n/a +e.a!a #a*a (m(mn/a tert(n*a )e)era#a min++(, )(!an
*an
 )ah"an )e)era#a tah(n sete!ah -e*era #ertama& Tra(ma #ertama mer)e"
sa!ah sat( ena /an+ me!eati r(an+an s()*(ra!& Ter.a*i #er*arahan se-
ara !am)at
*a!am r(an+an s()*(ra!& Da!am 7 sam#ai 10 hari sete!ah #er*arahan ter.*i, *arah
*i"e!i!in+i !eh mem)rane i)rsa& Den+an a*an/a se!isih te"anan smti-
/an+ mam#( menari" -airan "e *a!am hematma, ter.a*i "er(sa"an se!4se! *arah
*a!am hematma& Penam)ahan ("(ran hematma ini /an+ men/e)a)"an
#er*arahan
!e)ih !an.(t *en+an mer)e" mem)ran ata( #em)(!(h *arah *i se"e!i!
in+n/a,
menam)ah ("(ran *an te"anan hematma&
Hematma s()*(ra! /an+ )ertam)ah !(as se-ara #er!ahan #a!in+ serin+ ter.a*i
 #a*a (sia !an.(t "arena enan/a ra#(h *an #a*a a!"h!i"& Pa*a "e*(a "ea*aan
ini, -e*era tam#a"n/a rin+an, se!ama )e)era#a min++( +e.a!an/a
ti*a" 
*ihira("an& Hasi! #emeri"saan ;T s-an *an MRI )isa men(n.(""an
a*an/a
+enan+an *arah&
 Hematma s()*(ra! /an+ "e-i! #a*a *easa serin+"a!i *isera# se-ara s#ntan&
Hematma s()*(ra! /an+ )esar, /an+ men/e)a)"an +e.a!a4+e.a!a ne(r!
+is
 )iasan/a *i"e!(ar"an me!a!(i #em)e*ahan& Pet(n.(" *i!a"("ann/a #en+a!iran
 #er*arahan ini a*a!ah<
a& sa"it "e#a!a /an+ meneta#
 )& rasa men+ant(" /an+ hi!an+4tim)(!
-& !in+!(n+
*& #er()ahan in+atan
e& "e!(m#(han rin+an #a*a sisi t()(h /an+ )er!aanan&

D& PEMERIKSAAN DIA'NOSTIK 

1& ;T4S-an *en+an ata( tan#a "ntras< Men+i*entii"asi !(asn/a !esi, #er*arahan,
*eterminan entri"(!er, *an #er()ahan .arin+an ta"& ;atatan < Unt(" men+etah(i
a*an/a inar" = is"emia .an+an *i!a"("an #a*a 2$ 4 72 .am sete!ah in.(ri&
2& MRI< Di+(na"an sama se#erti ;T4S-an *en+an ata( tan#a "ntras ra*ia"ti&
3& ;ere)ra! An+i+ra#h/< Men(n.("an anma!i sir"(!asi -ere)ra!, se#erti< #er()ahan
 .arin+an ta" se"(n*er men.a*i (*ema, #er*arahan *an tra(ma&
$& Seria! EE'< Da#at me!ihat #er"em)an+an +e!m)an+ /an+ #at!+is&
>& ?4Ra/< Men*ete"si #er()ahan str("t(r t(!an+ ra"t(r, #er()ahan str("t(r +aris
#er*arahan=e*ema, ra+men t(!an+&
@& %AER< Men+re"si )atas (n+si -rte"s *an ta" "e-i!&
7& PET< Men*ete"si #er()ahan a"tiitas meta)!isme
ta"&
8& ;S6, L(m)a! P(n"si< Da#at *i!a"("an .i"a *i*(+a ter.a*i
#er*arahan
s()ara-hni*&
& A%'s< Men*ete"si "e)era*aan enti!asi ata( masa!ah #erna#asan "si+enisasi
 .i"a ter.a*i #enin+"atan te"anan intra"rania!&
10&Ka*ar E!e"tr!it< Unt(" men+"re"si "eseim)an+an e!e"tr!it se)a+ai
a"i)at
 #enin+"atan te"anan intr"rania!
11&S-reen T9i-!+i< Unt(" men*ete"si #en+ar(h )at sehin++a
men/e)a)"an
 #en(r(nan "esa*aran&

E& PENATALAKSANAAN
1& Knserati<
a& %e*rest t ta!
 )& Pem)erian )at4)atan
-& O)serasi tan*a4tan*a ita! ';S *an tin+"at
"esa*aran 2& Priritas Peraatan<
 a& Ma"sima!"an #er(si = (n+si ta" 
 )& Men-e+ah "m#!i"asi
-& Pen+at(ran (n+si se-ara #tima! = men+em)a!i"an "e (n+si nrma!
*& Men*("(n+ #rses #em(!ihan "#in+ "!ien = "e!(ar+a
e& Pem)erian inrmasi tentan+ #rses #en/a"it, #r+nsis, ren-ana #en+)atan,
*an reha)i!itasi&

II& KONSEP ASUHAN KEPERABATAN

A& PEN'KA5IAN
1& I*entitas "!ien *an "e!(ar+a #enan++(n+ .aa)< nama, (m(r, .enis
"e!amin, a+ama, s("( )an+sa, stat(s #er"ainan, a!amat, +!n+an *arah,
#en+ahasi!an, h()(n+an "!ien *en+an #enan++(n+ .aa)&
2& Ria/at "esehatan< a"t( "e.a*ian, #en/e)a) tra(ma, #sisi saat "e.a*ian,
stat(s "esa*aran saat "e.a*ian, #ert!n+an /an+ *i)eri"an se+era sete!ah
"e.a*ian&
3& Pemeri"saan isi" 
a& Sistem res#irasi < s(ara naas, #!a naas "(sma(!!, -he/ene
st"es, )it, hi#erenti!asi, ata"si"
 )& Kar*ias"(!er < #en+ar(h #er*arahan r+an ata( #en+ar(h PTIK 
-& Sistem sara <
1 Kesa*aran  ';S&

2 6(n+si sara "rania!  tra(ma /an+ men+enai=me!(as "e )atan+ ta"

a"an me!i)at"an #en(r(nan (n+si sara "rania!&
3 6(n+si sensri4mtr  a*a"ah "e!(m#(han, rasa )aa!, n/eri, +an++
(an
*is"riminasi s(h(, anestesi, hi#estesia, hi#era!+esia, ria/at "e.an+&
Skala Koma Glasgow
No RESPON NILAI
1 Membuka Mata <
4S#ntan $
4Terha*a# ran+san+an s(ara 3
4Terha*a# n/eri 2
4Ti*a" a*a 1
2 e!bal "
4Orientasi )ai"  >
4Orientasi ter+an++( $
4Kata4"ata ti*a" .e!as 3
4S(ara ti*a" .e!as 2
 4Ti*a" a *a re s#n 1
3 Moto!#k "
4 Mam#( )er+era"  @
4Me!"a!isasi n/eri >
46!e"si menari"  $
46!e"si a)nrma! 3
4E"stensi 2
4Ti*a" a*a res#n 1
Total 341>

*& Sistem #en-ernaan

1 %a+aimana sensri a*an/a ma"anan *i m(!(t, re!e"s mene!
an, "emam#(an men+(n/ah, a*an/a re!e"s )at(", m(*ah terse*a"&
5i"a
 #asien sa*ar  tan/a"an #!a ma"anC
2 Bas#a*ai (n+si ADH, a!*stern < retensi natri(m *an -
airan& 3 Retensi (rine, "nsti#asi, in"ntinensia&
e& Kemam#(an )er+era" < "er(sa"an area mtri"   hemi#aresis=#!
e+ia,
+an++(an +era" !(nter, ROM, "e"(atan tt&
& Kemam#(an "m(ni"asi < "er(sa"an #a*a hemiser *minan  *isa+ia

ata( aasia a"i)at "er(sa"an sara hi#+!s(s *an sara asia!is&

+& Psi"ssia!  *ata ini #entin+ (nt(" men+etah(i *("(n+an /an+
*i*a#at
 #asien *ari "e!(ar+a&

%& DIA'NOSA KEPERABATAN

1& 'an++(an #!a na#as )erh()(n+an *en+an *e#resi #a*a #(sat na#as *i
ta"& 2& Inee"ti "e)ersihan .a!an na#as )erh()(n+an *en+an #en(m#("an
s#(t(m& 3& 'an++(an #er(si .arin+an ta" )erh()(n+an *en+an (*em ta"&
$& Int!eransi a"tiitas )erh()(n+an *en+an #en(r(nan "esa*aran
s#rs 4
-ma&
>& Risi" +an++(an inte+ritas "(!it )erh()(n+an *en+an imm)i!isasi,
ti*a" a*e"(atn/a sir"(!asi #erier&
@& N/eri )erh()(n+an *en+an tra(ma "e#a!a&
7& Ke-emasan "e!(ar+a )erh()(n+an "ea*aan /an+ "ritis #a*a #asien&
 8& K(ran+n/a #eraatan *iri )erh()(n+an *en+an tirah )arin+ *an
men(r(nn/a "esa*aran&
& Risi" "(ran+n/a !(me -airan )erh()(n+an m(a! *an m(ntah&
10& Risi" in.(ri )erh()(n+an *en+an men(r(nn/a "esa*aran ata(
menin+"atn/a te"anan intra"rania!&
11& Risi" ine"si )erh()(n+an *en+an "n*isi #en/a"it a"i)at tra(ma "e#a!a&

;& INTERENSI KEPERABATAN

1& 'an++(an #!a na#as )erh()(n+an *en+an *e#resi #a*a #(sat na#as
*i
ta"&
Tujuan < Mem#ertahan"an #!a na#as /an+ ee"ti me!a!(i enti!atr&
 Kriteria evaluasi <
Pen++(naan tt )ant( na#as ti*a" a*a, siansis ti*a" a*a ata( tan*a4tan*a
hi#"sia ti*a" a*a *an +as *arah *a!am )atas4)atas nrma!&
 Rencana tindakan <
a& Hit(n+ #erna#asan #asien *a!am sat( menit& Perna#asan /an+ -e#at *ari
 #asien *a#at menim)(!"an a!"a!sis res#iratri *an #erna#asan !
am)at menin+"at"an te"anan Pa ;O 2  *an men/e)a)"an asi*sis
res#iratri"&
 )& ;e" #emasan+an t()e, (nt(" mem)eri"an enti!asi /an+ a*e"(at
*a!am
 #em)erian ti*a! !(me&
-& O)serasi rati ins#irasi *an e"s#irasi #a*a ase e"s#irasi )iasan/a 2
9
!e)ih #an.an+ *ari ins#irasi, ta#i *a#at !e)ih #an.an+ se)a+ai "m#ensasi
ter#eran+"a#n/a (*ara terha*a# +an++(an #ert("aran +as&
*& Perhati"an "e!em)a)an *an s(h( #asien "ea*aan *ehi*rasi
*a#at men+erin+"an se"resi = -airan #ar( sehin++a men.a*i
"enta! *an menin+"at"an resi" ine"si&
e& ;e" se!an+ enti!atr setia# a"t( 1> menit, a*an/a
)str("si *a#at menim)(!"an ti*a" a*e"(atn/a #en+a!iran !(me
*an menim)(!"an
 #en/e)aran (*ara /an+ ti*a" a*e"(at&
& Sia#"an am)( )a+ teta# )era*a *i *e"at #asien, mem)ant( mem)ari"an
enti!asi /an+ a*e"(at )i!a a*a +an++(an #a*a enti!atr&
2& Inee"ti "e)ersihan .a!an na#as )erh()(n+an *en+an
#en(m#("an s#(t(m&
Tujuan < Mem#ertahan"an .a!an na#as *an men-e+ah as#irasi
 Kriteria Evaluasi <
S(ara na#as )ersih, ti*a" ter*a#at s(ara se"ret #a*a se!an+ *an )(n/i a!arm
"arena #enin++ian s(ara mesin, siansis ti*a" a*a&
 Rencana tindakan <
a& Ka.i *en+an "etat tia# 1> menit "e!an-aran .a!an na#as& O)str("si *a#at
*ise)a)"an #en+(m#(!an s#(t(m, #er*arahan, )rn-hs#asme ata(
masa!ah terha*a# t()e&
 )& Ea!(asi #er+era"an *a*a *an a(s"(!tasi *a*a tia# 1 .am &
Per+era"an
/an+ simetris *an s(ara na#as /an+ )ersih in*i"asi #emasan+an t()e /an+
te#at *an ti*a" a*an/a #en(m#("an s#(t(m&
-& La"("an #en+isa#an !en*ir *en+an a"t( "(ran+ *ari 1> *eti" )i!a s#(t(m
 )an/a"& Pen+isa#an !en*ir ti*a" se!a!( r(tin *an a"t( har(s
*i)atasi (nt(" men-e+ah hi#"sia&
*& La"("an isitera#i *a*a setia# 2 .am& Menin+"at"an enti!asi
(nt(" sem(a )a+ian #ar( *an mem)eri"an "e!an-aran a!iran serta
#e!e#asan s#(t(m&
3& 'an++(an #er(si .arin+an ta" )erh()(n+an *en+an (*em ta" 
Tujuan : Mem#ertahan"an *an mem#er)ai"i tin+"at "esa*aran
(n+si mtri"&
 Kriteria hasil <
Tan*a4tan*a ita! sta)i!, ti*a" a*a #enin+"atan intra"rania!&
 Rencana tindakan <
a& Mnitr *an -atat stat(s ne(r!+is *en+an men++(na"an met*e
';S& Rasina! < Re!e"s mem)("a mata menent("an #em(!ihan
tin+"at "esa*aran&
Res#n mtri" menent("an "emam#(an )eres#n terha*a#
stim(!(s e"sterna! *an in*i"asi "ea*aan "esa*aran /an+ )ai"&
 Rea"si #(#i! *i+era"an !eh sara "rania! -(!(s mtri(s *an
(nt(" menent("an re!e"s )atan+ ta"&
Per+era"an mata mem)ant( menent("an area -e*era *an tan*a
aa!
 #enin+"atan te"anan intra-rania! a*a!ah ter+an++(n/a a)*("si mata&
 )& Mnitr tan*a4tan*a ita! tia# 30 menit&
Penin+"atan sist!i" *an #en(r(nan *iast!i" serta #en(r(nan
tin+"at
"esa*aran *an tan*a4tan*a #enin+"atan te"anan intra"rania!&
A*an/a
 #erna#asan /an+ irre+(!er in*i"asi terha*a# a*an/a #enin+"atan
meta)!isme se)a+ai rea"si terha*a# ine"si&
Unt(" men+etah(i tan*a4tan*a "ea*aan s/" a"i)at #er*arahan&
-& Pertahan"an #sisi "e#a!a /an+ se.a.ar *an ti*a" mene"an&
Per()ahan "e#a!a #a*a sat( sisi *a#at menim)(!"an #ene"anan #a*a ena
 .(+(!aris *an men+ham)at a!iran *arah ta", (nt(" it( *a#at menin+"at"an
te"anan intra"rania!&
*& Hin*ari )at(" /an+ )er!e)ihan, m(ntah, men+e*an, #ertahan"an
 #en+("(ran (rin *an hin*ari "nsti#asi /an+ )er"e#an.an+an&
Da#at men-et(s"an res#n tmati" #enn+"atan intra"rania!&
e& O)serasi "e.an+ *an !in*(n+i #asien *ari -e*era a"i)at
"e.an+&
Ke.an+ ter.a*i a"i)at iritasi ta", hi#"sia, *an "e.an+ *a#at menin+"at"an
te"anan intra"rania&
& %eri"an "si+en ses(ai *en+an "n*isi #asien&
Da#at men(r(n"an hi#"sia ta"&
+& %eri"an )at4)atan /an+ *iin*i"asi"an *en+an te#at *an
)enar 
"!a)rasi& Mem)ant( men(r(n"an te"anan intra"rania! se-ara )i!+i =
"imia se#erti smti" *i(riti" (nt(" menari" air *ari se!4se! ta" sehin++a
*a#at men(r(n"an (*em ta", steri* *e9ametasn (nt(" men(r(n"an
in!amasi, men(r(n"an e*ema .arin+an& O)at anti "e.an+
(nt(" men(r(n"an "e.an+, ana!+eti" (nt(" men(r(n"an rasa n/eri ee"
ne+ati 
*ari #enin+"atan te"anan intra"rania!& Anti#ireti" (nt(" men(r(n"an #anas
/an+ *a#at menin+"at"an #ema"aian "si+en ta"&

$& Int!eransi a"tiitas )erh()(n+an *en+an #en(r(nan "esa*aran

s#rs 4 -ma
Tujuan < Ke)(t(han *asar #asien *a#at ter#en(hi se-ara a*e"(at&
 Kriteria hasil <
 Ke)ersihan ter.a+a, "e)ersihan !in+"(n+an ter.a+a, n(trisi ter#en(hi ses(ai
*en+an "e)(t(han, "si+en a*e"(at&
 Rencana Tindakan <
a& %eri"an #en.e!asan tia# "a!i me!a"("an tin*a"an #a*a #asien& Pen.e!
asan *a#at men+(ran+i "e-emasan *an menin+"at"an "er.a sama
/an+ *i!a"("an #a*a #asien *en+an "esa*aran #en(h ata( men(r(n&
 )& %eri )ant(an (nt(" memen(hi "e)ersihan *iri&
Ke)ersihan #erran+an, e!iminasi, )er#a"aian, man*i, mem)ersih"an mata
*an "("(, m(!(t, te!in+a, mer(#a"an "e)(t(han *asar a"an "en/amanan
/an+ har(s *i.a+a !eh #eraat (nt(" menin+"at"an rasa
n/aman, men-e+ah ine"si *an "ein*ahan&
-& %eri"an )ant(an (nt(" memen(hi "e)(t(han n(trisi *an -airan&
Ma"anan *an min(man mer(#a"an "e)(t(han sehari4hari /an+
har(s
*i#en(hi (nt(" men.a+a "e!an+s(n+an #er!ehan ener+i& Di)eri"an ses(ai
*en+an "e)(t(han #asien )ai" .(m!ah, "a!ri, *an a"t(&
*& 5e!as"an #a*a "e!(ar+a tin*a"an /an+ *a#at *i!a"("an (nt("
men.a+a
!in+"(n+an /an+ aman *an )ersih&
Kei"(tsertaan "e!(ar+a *i#er!("an (nt(" men.a+a h()(n+an "!ien
4
"e!(ar+a& Pen.e!asan #er!( a+ar "e!(ar+a *a#at memahami #erat(ran /an+
a*a *i r(an+an&
e& %eri"an )ant(an (nt(" memen(hi "e)ersihan *an "eamanan
!in+"(n+an& Lin+"(n+an /an+ )ersih *a#at men-e+ah ine"si
*an "e-e!a"aan&

>& Risi" +an++(an inte+ritas "(!it )erh()(n+an *en+an imm)i!

isasi, ti*a" a*e"(atn/a sir"(!asi #erier&
Tujuan < 'an++(an inte+ritas "(!it ti*a" ter.a*i
 Rencana tindakan <
a& Ka.i (n+si mtri" *an sensri" #asien *an sir"(!asi #erier

(nt(" 
meneta#"an "em(n+"inan ter.a*in/a !e-et #a*a "(!it&
 )& Ka.i "(!it #asien setia# 8 .am < #a!#asi #a*a *aerah /an+ terte"an&
-& %eri"an #sisi *a!am si"a# anatmi *an +(na"an tem#at "a"i (nt(" *aerah
/an+ menn.!&
*& 'anti #sisi #asien setia# 2 .am

e& Pertahan"an "e)ersihan *an "e"erin+an #asien < "ea*aan !em)a)

a"an
mem(*ah"an ter.a*in/a "er(sa"an "(!it&
& Massa+e *en+an !em)(t *i atas *aerah /an+ menn.! setia# 2 .am se"a!i&
+& Pertahan"an a!at4a!at ten(n teta# )ersih *an te+an+&
 h& Ka.i *aerah "(!it /an+ !e-et (nt(" a*an/a eritema, "e!(ar -airan setia# 8
 .am&
i& %eri"an #eraatan "(!it #a*a *aerah /an+ r(sa" = !e-et setia# $ 4 8 .am
*en+an men++(na"an H2O2&

@& N/eri )erh()(n+an *en+an tra(ma "e#a!a&

Tujuan< K!ien a"an merasa n/aman /an+ *itan*ai *en+an "!ien
ti*a" men+e!(h n/eri, *an tan*a4tan*a ita! *a!am )atas nrma!&

 Intervensi<
a& Ka.i "e!(han n/eri *en+an men++(na"an s"a!a n/eri, -atat !"asi n/eri,
!aman/a, seran+ann/a, #enin+"atan na*i, naas -e#at ata( !am)at,
 )er"erin+at *in+in&
 )& Men+at(r #sisi ses(ai "e)(t(han ana" (nt(" men+(ran+i n/eri&
-& K(ran+i ran+san+an&
*& Pem)erian )at ana!+eti" ses(ai *en+an #r+ram&
e& ;i#ta"an !in+"(n+an /an+ n/aman termas(" tem#at ti*(r&
& %eri"an sent(han tera#e(ti", !a"("an *istra"si *an re!a"sasi&

7& Ke-emasan "e!(ar+a )erh()(n+an "ea*aan /an+ "ritis #a*a #asien&

Tujuan < Ke-emasan "e!(ar+a *a#at )er"(ran+
 Kriteri evaluasi <
E"s#resi a.ah ti*a" men(n.an+ a*an/a "e-emasan
Ke!(ar+a men+erti -ara )erh()(n+an *en+an #asien
Pen+etah(an "e!(ar+a men+enai "ea*aan, #en+)atan *an tin*a"an
menin+"at&
 Rencana tindakan <
a& %ina h()(n+an sa!in+ #er-a/a&
Unt(" mem)ina h()(n+an ter#i(ti" #eraat 4 "e!(ar+a&
 )& Den+ar"an *en+an a"ti *an em#ati, "e!(ar+a a"an merasa *i#erhati"an&
-& %eri #en.e!asan tentan+ sem(a #rse*(r *an tin*a"an /an+ a"an *i!a"("an
 #a*a #asien& Pen.e!asan a"an men+(ran+i "e-emasan a"i)at
"eti*a" tah(an&
*& %eri"an "esem#atan #a*a "e!(ar+a (nt(" )ertem( *en+an "!
ien& Mem#ertahan"an h()(n+an #asien *an "e!(ar+a&
e& %eri"an *rn+an s#irit(a! (nt(" "e!(ar+a&
Seman+at "ea+amaan *a#at men+(ran+i rasa -emas *an
menin+"at"an
"eimanan *an "eta)ahan *a!am men+ha*a#i "risis&
8& K(ran+n/a #eraatan *iri )erh()(n+an *en+an tirah )arin+
*an men(r(nn/a "esa*aran&
Tujuan< Ke)(t(han sehari4hari ana" ter#en(hi /an+ *itan*ai *en+an
)erat
 )a*an sta)i! ata( ti*a" men(n.(""an #en(r(nan )erat )a*an, tem#at
ti*(r 
 )ersih, t()(h ana" )ersih, ti*a" a*a iritasi #a*a "(!it, )(an+ air
)esar *an "e-i! *a#at *i)ant(&
 Intervensi<
a& %ant( ana" *a!am memen(hi "e)(t(han a"tiitas, ma"an 
min(m,
men+ena"an #a"aian, %AK *an %A%, mem)ersih"an tem#at
ti*(r, *an "e)ersihan #erseran+an&
 )& %eri"an ma"anan ia #arentera! )i!a a*a in*i"asi&
-& Peraatan "ateter )i!a ter#asan+&
*& Ka.i a*an/a "nsti#asi, )i!a #er!( #ema"aian #e!em)e" tin.a
(nt(" 
mem(*ah"an %A%&
e& Li)at"an ran+ t(a *a!am #eraatan #emen(han "e)(t(han sehari4hari
*an *emnstrasi"an, se#erti )a+aimana -ara meman*i"an ana"&

& Risi" "(ran+nn/a !(me -airan )erh()(n+an *en+an m(a!

*an m(ntah&
Tujuan< Ti*a" *item("an tan*a4tan*a "e"(ran+an !(me -a/ran
ata(
*ehi*rasi /an+ *itan*ai *en+an mem)ran m("sa !em)a), inte+ritas
"(!it )ai", *an ni!ai e!e"tr!it *a!am )atas nrma!&
 Intervensi<
a& Ka.i in ta"e * an  (t # (t&
 )& Ka.i tan*a4tan*a *ehi*rasi< t(r+r "(!it,
mem)ran m("sa, *an ()(n4()(n ata( mata -e"(n+ *an (t #(t (rine&
-& %eri"an - airan i ntra  ena s es(ai #
r+ram&

10& Risi" in.(ri )erh()(n+an *en+an men(r(nn/a "esa*aran ata(

menin+"atn/a te"anan intra"rania!&
Tujuan< Ana" ter)e)as *ari in.(ri&

 Intervensi<
 a& Ka.i stat(s ne(r!+is ana"< #er()ahan "esa*aran, "(ran+n/a
res#n
terha*a# n/eri, men(r(nn/a re!e"s, #er()ahan #(#i!, a"tiitas #er+era"an
men(r(n, *an "e.an+&
 )& Ka.i tin+"at "esa*aran *en+an ';S
-& Mnitr tan*a4tan*a ita! ana" setia# .am ata( ses(ai *en+an #rt"!&
*& %eri"an istirahat antara interensi ata(
#en+)atan& e& %eri"an ana!+eti" ses(ai #r+ram&

11& Risi" ine"si )erh()(n+an *en+an a*an/a in.(ri&

Tujuan< K!ien a"an ter)e)as *ari ine"si /an+ *itan*ai *en+an
ti*a" 
*item("an tan*a4tan*a ine"si< s(h( t()(h *a!am )atas nrma!,
ti*a" a*a #(s *ari !("a, !e("sit *a!am )atas nrma!&
 Intervensi<
a& Ka.i a*an/a *raina+e #a*a area !("a&
 )& Mnitr tan*a4tan*a ita!< s(h( t()(h&
-& La"("an #eraatan !("a *en+an steri! *an hati4hati&
*& Ka.i tan*a *an +e.a!a a*an/a menin+itis, termas(" "a"( "(*(",
irita)e!,
sa"it "e#a!a, *emam, m(ntah *an "en.an+&

D& IMPLEMENTASI
Peren-anaan *ises(ai"an *en+an "n*isi *an res#n "!ien

E& EALUASI
1& Pen++(naan tt )ant( na#as ti*a"
a*a 2& S(ara na#as )ersih
3& Ti*a" a*a #enin+"atan intra"rania!&
$& Tan*a4tan*a ita! sta)i!
>& Ke)ersihan ter.a+a
@& a.ah ti*a" men(n.an+ a*an/a "e-emasan
7& Ke!(ar+a men+erti -ara )erh()(n+an *en+an #asien
8& Pen+etah(an "e!(ar+a men+enai "ea*aan, #en+)atan *an tin*a"an menin+"at&

DA6TAR PUSTAKA

H(*a N(rari, Amin, Har*i K(s(ma&2013 &Aplikasi Asuhan Keperawatan berdasarkan diagnosa

medis dan NANDA NI!N" #ilid $%&'+/a"arta<Me*ia-tin&
5(a!! ;ar#enit4M/et, L/n*a&2007 &(uku )aku Diagnosa
Keperawtan'5a"arta<E';& A&Pri-e,S/!ia, Lrraine M& Bi!
sn&200@ &*AT"+I)I","-I #ilid $'5a"arta<E';&
Men+etah(i Den#asar, Nem)er 2 01$
Pem)im)in+ Pr a"ti" Mahasisa

 I Ma*e S(maharianta Ra*in 

 NIM& P07120012083

Men+etah(i
Pem)im)in+
A"a*emi"