M DENGAN
DIAGNOSA MEDIS HIDROCEPHALUS RSU
UNIVERSITAS MUHAMMADIYAH MALANG
MAULUTFI PRASTIAWAN
(NIM: 202110461011138)
i
ASUHAN KEPERAWATAN PADA Ny. M DENGAN
DIAGNOSA MEDIS HIDROCEPHALUS RSU
UNIVERSITAS MUHAMMADIYAH MALANG
Disusun Oleh:
MAULUTFI PRASTIAWAN
(NIM: 202110461011138)
ii
LEMBAR PERSETUJUAN
Judul Karya Ilmiah Akhir Ners : Asuhan Keperawatan Hidrochepalus
Pada Ny.M Dengan Masalah
Keperawatan Nyeri Akut Di
Ruang Mawar RSU
Universitas
Muhammadiyah Malang
Nama Lengkap : Maulutfi Prastiawan
NIM 202110461011138
Jurusan : Profesi Ners
Universitas : Universitas
Muhammadiyah Malang
Alamat Rumah Dan No Telepon/HP : Jl. Imam Bonjol Gg II No.18H
Sisir
Kota Batu / 081259606837
Alamat Email : maulutfiprastiawan@gmail.com
Dosen Pembimbing
Nalam Lengkap Dan Gelar : Edi Purwanto, S.Kep.,
Ns., MNg.NIP UMM/NIDN 0716098102
Alamat Rumah Dan No. Telepon/HP : 0812-1612-2117
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LEMBAR PENGESAHAN
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KATA PENGANTAR
Dengan menyebut nama Allah SWT yang Maha Pengasih lagi Maha Penyayang,
puji dan syukur atas kehadirat-Nya, yang telah melimpahkan rahmat, hidayah, dan
inayah-Nya, penulis dapat menyelesaikan KIAN dengan judul “Asuhan
dukungan dan bimbingan dari berbagai pihak. Untuk itu tidak lupa penulis
1. Kedua orang tua yang selalu memberikan doa terbaik, serta memberikan
dukungan untuk menyelesaikan KIAN ini.
2. Kepada istri saya yang selalu menemani dan memberi dukungan kepada
saya.
3. Teman-teman Ners 24, serta semua pihak yang telah memberikan semangat
dan membantu penyelesaian KIAN ini.
Penulis hanya mampu berdoa semoga amal kebaikannya mendapatkan imbalan dan
diterima sebagai ibadah oleh Allah SWT. Penulis menyadari terdapat banyak
kemampuan dan pengetahuan yang penulis miliki. Oleh karena itu, kritik dan saran
Penulis
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ABSTRAK
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ABSTRACT
Method : The research method in the preparation of this Final Scientific Paper uses
case studies. The author follows the scientific method according to the rules of the
Nursing Process which includes: Assessment, Data Analysis, Nursing Intervention,
Implementation and Evaluation. The collection techniques include: data such as
anamnesis, observation, study documentation and physical examination of data
from patients, namely Mrs. M. To complete the data, the author also conducted
interviews with the family of Mrs. M.
Result : After providing nursing care for 3 days in a row, the authors appointed 3
nursing diagnoses, namely: Acute Pain b.d Physiological Injury Agent, Decreased
Intracranial Adaptive Capacity b.d obstruction of cerebrospinal fluid flow, Neusea
b.d increased intracranial pressure. Use of evaluation model with deep breathing
technique and position Semi-Fowler's can relieve mild pain and intracranial
pressure.
1
Student nurses Studies Program, Faculty of Health Sciences, University of
Muhammadiyah Malang
2
Lecturer nurses Studies Program, Faculty of Health Sciences, University of
Muhammadiyah Malang
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DAFTAR ISI
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3.1 Pengkajian ...................................................................................................... 51
3.1.1 Identitas Pasien dan Penanggung Jawab .............................................. 51
3.1.2 Keluhan Utama ....................................................................................... 51
3.1.3 Diagnosa Medis ....................................................................................... 51
3.1.4 Riwayat Penyakit Sekarang ................................................................... 51
3.1.5 Riwayat Kesehatan Yang Lalu .............................................................. 52
3.1.6 Riwayat Penyakit Keluarga ................................................................... 52
3.1.7 Activity Daily Live .................................................................................. 52
3.1.8 Riwayat Psikologi ................................................................................... 53
3.1.9 Riwayat Sosial ......................................................................................... 53
3.1.10 Riwayat Spiritual .................................................................................... 53
3.1.11 Pemeriksaan Fisik .................................................................................. 53
3.2 Konsep Diri ..................................................................................................... 58
3.3 Tindakan dan Terapi ..................................................................................... 58
3.4 Analisa Data dan Diagnosa Keperawatan .................................................... 59
3.5 Rencana Keperawatan ................................................................................... 60
3.6 Implementasi Keperawatan ........................................................................... 62
3.6.1 Implementasi Diagnosa Keperawatan: Nyeri Akut b.d Agen
Pencedera Fisiologis ............................................................................................... 62
3.6.2 Penurunan Kapasitas Adaptif Intrakranial b.d obstruksi aliran cairan
cerebrospinal .......................................................................................................... 63
3.6.3 Neusea b.d peningkatan tekanan intrakranial ..................................... 64
3.7 Evaluasi ........................................................................................................... 65
BAB IV............................................................................................................................ 66
ANALISIS SITUASI ...................................................................................................... 66
4.1 Analisis Profil Pelayanan ............................................................................... 66
4.2 Analisis Masalah Keperawatan ..................................................................... 67
4.3 Analisis Intervensi .......................................................................................... 71
BAB V ............................................................................................................................. 77
PENUTUP ....................................................................................................................... 77
5.1 Kesimpulan ..................................................................................................... 77
5.2 Saran ............................................................................................................... 77
5.3 Keterbatasan................................................................................................... 78
DAFTAR PUSTAKA ...................................................................................................... 79
Lampiran 1. ASUHAN KEPERAWATAN .................................................................. 81
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A. Pengkajian (Focus Assesement) ........................................................................... 81
B. Analisa Data........................................................................................................ 94
C. Diagnosa Keperawatan (SDKI) ............................................................................ 95
D. Luaran Keperawatan (SLKI) ................................................................................ 96
E. Intervensi Keperawatan (SIKI) ............................................................................. 97
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Lampiran 2: Hasil plagiasi
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