ASUHAN KEPERAWATAN PADA Tn.

R DENGAN HIV AIDS

DI RUANG TERATAI
RSUD Dr. R. SOETIJONO BLORA
 Kelompok 8 :
1. Devi Wulan Oktaviana ( P1337420419101 )
2. Irma Febriana Damayanti ( P1337420419103 )
3. Adinda Sekar Sari ( P1337420419105 )
4. Rossa Oktalinda ( P1337420419107 )
5. Surya Baskara Jaya ( P1337420419109 )
6. Sofy Nur Oktamia ( P1337420419111 )
7. M.Syarifuddin Hidayatullah ( P1337420419113 )
A. PENGKAJIAN
I. IDENTITAS
IDENTITAS PASIEN
Nama : Tn. R
Umur : 40 Tahun
Alamat : Blora,Rt 01 Rw 02
Agama : Islam
Pendidikan : SLTA
Pekerjaan : Wiraswasta
Status : Menikah
Tanggal masuk RS : 17 Maret 2021
Diagnosa Medis : HIV-AIDS

IDENTITAS PENANGGUNG JAWAB

Nama : Ny. J
Umur : 37 Tahun
Alamat : Blora,Rt 01 Rw 02
Agama : Islam
Pendidikan : SLTA
Hubungan dgn pasien: Istri
II. RIWAYAT KESEHATAN
a. Riwayat Kesehatan Sekarang
1. Keluhan Utama
Pasien masuk RSUD Dr. R. Soetijono Blora melalui IGD pada tanggal 17 Maret 2021 jam 09.45 WIB
dirujuk dari RS. PKU MUHAMMIDYAH BLORA, dengan keluhan diare sejak 3 minggu yang lalu, konsistensi
cair dan berlendir, frekuensi 3 sampai 4 kali dalam sehari, BAB bewarna kuning, dan kadang berdarah,
pasien mengatakan badan terasa lemah dan letih
.

2. Keluhan Saat Dikaji

Pada saat pengkajian tanggal 18 Maret 2021 jam 11.00 WIB, didapatkan pasien dengan
kesadaran komposmentis, keadaan umum klien tampak lemah dan letih. Saat pengkajian pasien
mengatakan masih diare, frekuensi 4 sampai 5 kali dalam sehari, BAB cair, bewarna kuning
kadang berdarah serta berlendir, pasien mengeluhkan badan terasa lemah dan letih, nafsu
makan menurun, pasien mengatakan berat badan semakin berkurang BB sekarang 33 kg,
pasien mengatakan mulut sariawan serta bibir kering, pasien juga mengeluhkan kulit gatal-gatal
dan bewarna kemerahan.
b. Riwayat Kesehatan Dahulu

Dahulu Pasien mengatakan dua bulan yang

lalu pernah dirawat karena penyakit paru,
pasien mengatakan tidak mendapat terapi obat
paru, pasien mengatakan sudah berhenti
merokok sejak 2 bulan yang lalu, pasien
mengatakan pernah minum alkohol sewaktu
muda pasien mengatakan tidak pernah
mengkonsumsi narkoba, pasien mengatakan
pernah seks bebas sebelum menikah.

c. Riwayat Kesehatan Keluarga

Pasien mengatakan tidak ada anggota

keluarga yang memiliki penyakit HIV AIDS.
Pasien mengatakan tidak ada anggota keluarga
yang mempunyai penyakit keturunan seperti
Hipertensi, DM, Jantung serta penyakit TBC.
III. POLA AKTIVITAS SEHARI-HARI (ADL)
A. Pola Nutrisi

Saat sehat pasien makan 3 kali sehari pasien menkonsumsi nasi ditambah lauk pauk, sayur dan
habis dalam satu porsi, pasienkadang-kadang juga mengkonsumsi buah. Pasien minum air putih
01 Sehat 5-6 gelas/hari, pasien juga mengatakan sering mengkonsumsi kopi.

Pasien mengatakan nafsu makan berkurang sejak 1 bulan terakhir. Pasien mendapatkan diet ML
02 Sakit dan hanya dihabiskan 3-4 sendok.pasien sering mengeluhkan haus. Saat sakit pasien banyak
mengkonsumsi air putih ±800 ml perhari

B. Pola Eliminasi

BAB : pada saat sehat pasien BAB 1 kali sehari dengan konsistensi lunak bewarna kecoklatan.
01 Sehat BAK : pada saat sehat pasien BAK lebih kurang 6 kali sehari, pasien BAK dengan lancar

BAB : pasien mengatakan diare sejak 3 minggu sebelum masuk rumah sakit frekuensi 4-5 kali dalam
sehari, bewarna kuning terkadang berdarah, konsistensi cair dan berlendir.
02 Sakit Pasien BAK 5 sampai 7 kali sehari. pasien terpasang pempers, kebutuhan eliminasi pasien dilakukan
ditempat tidur.
A. Pola Aktivitas dan Latihan

01 Sehat Saat sehat pasien mampu melakukan aktifitas sehari hari secara mandiri.

02 Sakit Saat sakit aktivitas pasien lebih banyak di tempat tidur . aktivitas pasien dibantu keluarga.

B. Pola Bekerja

01 Sehat Saat sehat pasien bekerja sebagai petani karet, pasien bekerja 5 jam dalam sehari.

02 Sakit Pasien mengatakan sudah 6 minggu tidak bekerja karena badan terasa lelah dan letih.
IV. PEMERIKSAAN FISIK
A. Keadaan Umum
Tinggi badan : 153 cm
Berat badan : 33 kg
IMT : 14,10 (Berat badan kurang)
Lingkar lengan : 19 cm
Kesadaran : Composmentis Coperatif
Tekanan darah : 100/70 mmHg
Nadi : 110 x/i 8) Pernafasan : 19 x/i
Suhu : 37,0̊ C

B. Kepala
Kepala simetris, tidak ada pembengkakan pada kepala dan tidak ada lesi.

C. Wajah
Ekspresi wajah tampak tegang

D. Rambut
Rambut bewarna hitam, tampak kusam distribusi rambut merata, rambut mudah rontok dan berketombe.

E. Mata
Mata simetris kiri dan kanan, konjungtiva anemis, sklera tidak ikhterik,reflek cahaya positik kiri dan kanan, reflek pupil isokor,
ukuran pupil 2mm/2mm
F. Hidung
Hidung simetris, tidak terdapat pernafasan cuping hidung, tidak terdapat pembengkakan, tidak terdapat nyeri tekan.

G. Mulut
Bibir tampak kering dan pecah-pecah, terdapat condidiasis oral, terdapat sariawan, terdapat gigi yang berlubang

H. Telinga
Telinga simetris, tidak terdapat pembengkakan di area telinga, terdapat serumen di kedua telinga terdapat serumen di kedua telinga.

I. Leher
Leher simetris, tidak ada pembengkakan kelenjer getah bening, dan tidak terdap bendungan vena jugularis.

J. Paru-Paru
1) Inspeksi : Bentuk dada simetris kiri dan kanan, tidak terdapat retraks dinding dada, terdapat bantuan otot bantu pernafasan
2) Palpasi : Premitus kiri dan kanan sama
3) Perkusi : Sonor
4) Auskultasi :Vasikuler

K. Jantung
1. Inspeksi : Iktus kordis tidak terlihat
2. Palpasi :Ikhtus kordis teraba satu jari RIC 3
3. Perkusi : Pekak pada batas jantung
4. Auskultasi : reguler
L. Abdomen
1. Inspeksi : tidak terdapat pembengkakan atau asites pada Perut, tidak terdapat distensi abdomen.
2. Ausklutasi : bising usus 22x/i
3. Palpasi : saat dilakukan perkusi didapatkan suara timpani
4. Perkusi : hepar terba dan tidak ada nyeri tekan pada abdomen

M. Kulit
Kulit terlihat kering, terdapat tanda-tanda lesi (sarkoma kaposi), turgor kulit jelek.

N. Genitalia
Pasien mengatakan tidak ada keluhan di area kemaluan.

O. Ekstremitas
5. Atas : Pasien terpasang NaCL 0,9% 20 tetes/menit di tangan sebelah kanan, akral teraba dingin, tidak terdapat udema, kulit
kering CRT > 3 detik tonus otot melemah.
6. Bawah : terdapat udema, kulit kering, akral teraba dingin, CRT > 3 detik, tonus otot melemah.
V. DATA PSIKOLOGIS
a) Status Emosional (Emosi pasien stabil, pasien mampu diajak komunikasi)
b) Kecemasan (Pasien mengatakan perasaan cemas karena merasa kondisinya belum juga membaik,
pasien mengatakan tidak mengerti dengan penyakitnya saat ini)
c) Pola Koping (Pasien bersemangat dalam menjalani proses pengobatan,dan sabar dalam menjalani
penyakitnya saat ini)
d) Gaya Komunikasi (Pasien mampu diajak berkomunikasi, pasien mampu berkomunikasi secara
terbuka.)
e) Konsep diri diurai untuk komponen gambaran diri, harga diri, peran, identitas, dan ideal diri.
Pasien memiliki konsep diri yang baik, pasien ingin segera sembuh agar bisa kembali bekerja dan
berkumpul besama keluarga.

VI. DATA SOSIAL EKONOMI

Keluarga mengatakan pasien merupakan seseorang yang senag bersosialisasi dengan orang lain.
Pasien bekerja di kebun karet pasien mengatakan penghasilan bersihnya Rp. 2.000.000 perbulan.
Gajinya digunakan untuk membantu biaya ppendidikan anak anaknya dan juga membeli kebutuhan
rumah tangga. Pasien memakai kartu BPJS kelas II untuk pembiayaan di rumah sakit.
VII. DATA SPIRITUAL
Pasien merupakan seorang muslim dan berkeyakinan bahwa allah akan
memberikan kesembuhan kepadanya. pasien mengatakan dalam masih sering
meninggalkan shalat.
 
VIII. LINGKUNGAN TEMPAT TINGGAL
1. Tempat pembuangan kotoran : WC + sepctic tang
2. Tempat pembuangan sampah : dikumpul ke mobil sampaH
3. Pekarangan : hanya ada teras rumah
4. Sumber air minum : klien minum dengan air gallon
5. Pembuangan air limbah : klien buang air limbah diselokan depan di rumah
B. ANALISA DATA
DATA MASALAH PENYEBAB
 DS : Kekurangan volume cairan Kehilangan cairan aktif
a. Pasien mengatakana badan terasa lemah dan letih
b. Pasien mengatakan BAB cair
c. Frekuensi BAB 3 sampai 4 kali dalam sehari
d. Pasien merasakan sering merasa haus
e. Pasien mengatakan sering keringat malam
 DO :
a. Pasien tampak lemah
b. Bibir tampak kering
c. Turgor kulit Jelek
d. CRT > 3 detik
e. Kulit tampak kering
f. TD = 80/70 mmHg
g. N = 124 x/menit
h. Pasien mendapatkan terapi Nacl 0,9%

 DS : Diare Proses Infeksi

a. Pasien mengatakan diare seajak tiga minggu yang lalu
b. Pasien mengtakan konsentrasi BAB cair
c. Pasien mengatakan frekuensi diare 3 sampai 4 kali sehari,
konsistensi cair dan berlendir, bewarna kuning, kadang
kemerah merahan.
 DO:
a. Pasien tampak lemah
b. Bising usus 21 x/menit
c. TD : 90/60 mmHg
d. N : 124 x/menit
 DS : Diare Proses Infeksi
a. Pasien mengatakan diare seajak tiga minggu yang lalu
b. Pasien mengtakan konsentrasi BAB cair
c. Pasien mengatakan frekuensi diare 3 sampai 4 kali sehari,
konsistensi cair dan berlendir, bewarna kuning, kadang
kemerah merahan.
 DO:
a. Pasien tampak lemah
b. Bising usus 21 x/menit
c. TD : 90/60 mmHg
d. N : 124 x/menit
 DS: Ketidak seimbangan nutrisi Faktor biologis
a. Pasein mengatakan berat badan mengalami penurunan sejak kurang dari kebutuhan tubuh
sakit
b. Pasien mengatakan nafsu makan berkurang
c. Pasien mengatakan nafsu makan berkurang sejak sakit
d. Pasien mengatakan porsi makan hanya dihabiskan 3 sampai
4 sendok makan
 DO:
a. Pasien tampak kurus
b. Berat badan sekarang 33 kg
c. Tinggi badan 154 cm
d. IMT 14, 34 (Berat badan kurang)
e. Lingkar lengan 19
f. Porsi makan tampak tidak habis
g. Bising usus 21 x/menit
h. Bibir kering
i. Terdapat sariawan
j. Tonus otot melemah
C. DIAGNOSA KEPERAWATAN

1. Kekurangan volume cairan berhubungan dengan

Kehilangan cairan aktif
2. Diare berhubungan dengan Proses Infeksi
3. Ketidak seimbangan nutrisi kurang dari kebutuhan
tubuh berhubungan dengan faktor biologis,
ketidakmampuan menelan.
D. INTERVENSI KEPERAWATAN
Tanggal No. Tujuan dan KH Intervensi TTD
Dx

17 Maret 2021 I Setelah dilakukan tindakan keperawatan diharapkan keseimbangan  Manajemen cairan :
cairan cairan tidak terganggu dengan kriteria hasil : a. Timbang berat badan setiap hari dan monitor status pasien
a. Tekanan darah tidak terganggu b. Jaga intake asupan dan catat output pasien
b. Keseimbangan intake dan output dalam 24 jam tidak terganggu c. Monitor status hidrasi (misalnya membrane mukosa lembab,
c. Berat badan stabil tidak terganggu denyut nadi adekuat, dan tekanan darah ortostatik)
d. Tugor kulit tidak terganggu d. Monitor hasil laboratorium yang relevan dengan retensi cairan
(misalnya peningkatan berat badan, penurunan hematokrit, dan
Setelah dilakukan tindakan keperawatan diharapkan hidrasi tidak terganggu peningkatan kadar osmolitas (urin)
dengan kriteria hasil : e. Monitor status hemodinamik CVP, MAP, PAP, dan PCWP (jika
ada)
e. Tugor kulit tidak terganggu
f. Monitor TTV
f. Membran mukosa lembab tidak terganggu
g. Beri terapi IV, seperti yang ditentukan
g. Intake cairan tidak terganggu
h. Berikan cairan dengan tepat
h. Output cairan tidak terganggu
i. Berikan diuretic yang diresepkan
i. Perfusi jaringan tidak terganggu
j. Distribusi asupan cairan selama 24 jam
j. Tidak ada nadi cepat lemah
 Monitor Cairan :
k. Tidak ada kehilangan berat badan
a. Tentukan jumlah dan jenis intake asupan cairan serta kebiasaan
eliminasi
b. Tentukan faktor-faktor yang menyebabkan ketidakseimbangan
cairan
c. Periksa isi kulang kapiler
d. Periksa tugor kulit
e. Monitor berat badan
f. Monitor nilai kadar serum dan elektrolit urine
g. Monitor kadar serum albumin dan protein total
h. Monitor tekanan darah, denyut jantung, dan status pernafasan
18 Maret 2021 II Setelah dilakukan tindakan keperawatan diharapkan eliminasi usus tidak  Manajemen saluran cerna :
terganggu dengan kriteria hasil : Monitor BAB termasuk frekuensi, konsistensi, bentuk, volume
a. Pola eliminasi tida terganggu dan warna, dengan cara yang tepat.
b. Suara bising usus tidak terganggu  Manajemen diare
c. Diare tidak ada a. Tentukan riwayat diare
b. Ambil tinja untuk pemeriksaan kultur dan sensitifitas bila diare
Setelah dilakukan tindakan keperawatan diharapkan tidak terjadi keparahan berlanjut
infeksi dengan kriteria hasil : c. Instruksikan pasien atau anggota keluarga untuk mencatat
warna, volume, frekuensi, dan konsistensi tinja
d. Malaise tidak ada
d. Identifikasi faktor yang bisa menyebabkan diare ( misalnya
e. Nyeri tidak ada
medikasi, bakteri, dan pemberian makan lewat selang)
f. Depresi jumlah sel darah putih
e. Amati tugor kulit secara berkala
f. Monitor kulit perineum terhadap adanya iritasi dan ulserasi
g. Konsultasikan dengan dokter jika ada tanda dan gejala diare
menetap
 Pemasangan infuse
a. Verifikasi instruksi untuk terapi IV
b. Beritahu pasien mengenai prosedur
c. Pertahankan teknik aseptic secara seksama
d. Pilih vena yang sesuai dengan penusukan vena, pertimbangkan
prevelansi pasien, pengalaman masa lalu dengan infus, dan
tangan non dominan
e. Berikan label pada pembalut dengan tanggal, ukuran, dan
insiasi sesuai protokol lembut
 Terapi intravena (IV)
a. Verifikasi perintah untuk terapi intravena
b. Instrusikan pasien tentang prosedur
c. Periksa tipe cairan, jumlah, kadaluarsa, karakteristik dan cairan,
dan tingkat merusak pada container
d. Lakukan (prinsip) 5 benar sebelum memulai infuse atau
pemberian pengobatan (benar obat, benar dosis, benar pasien,
benar cara, dan benat frekuensi)
e. Monitor kecepatan IV, sebelum memberikan pengobatan IV
f. Monitor TTV
19 Maret III Setelah dilakukan tindakan keperawatan diharapkan status  Manajemen nutrisi
2021 nutrisi dapat ditingkatkan dengan kriteria hasil : Identifikasi adanya alergi atau intoleransi makanan
a. Asupan nutrisi tidak menyimpang dari rentang normal. yang dimiliki pasien
b. Asupan makanan tidak menyimpang dari rentang normal  Terapi nutrisi
1. Kaji kebutuhan nutrisi parenteral
Setelah dilakukan tindakan keperawatan diharapkan status nutrisi : 2. Berikan nutrisi enteral sesuai kebutuhan
asupan nutrisi dapat ditingkatkan dengan kriteria hasil: 3. Berikan nutrisi enteral
c. Asupan kalori sebagian besar adekuat 4. Hentikan pemberian makanan melalui selang makan
d. Asupan protein sebagian besar adekuat begitu pasien mampu mentoleransi asupan (makanan)
e. Asupan lemak sebagian adekuat melalui oral
f. Asupan karbohidrat sebagian adekuat 5. Berikan nutrisi yang dibutuhkan sesuai batas diet
g. Asupan vitamin sebagian adekuat yang dianjurkan
h. Asupan mineral sebagian adekuat  Pemberian nutrisi total parenteral (TPN)
1. Pastikan isersi intravena cukup paten untuk
Setelah dilakukan tindakan keperawatan diharapkan terjadi pemberian nutrisi intravena
peningkatan nafsu makan dengan kriteria hasil : 2. Pertahakanan kecepatan aliran yang konstan
3. Monitor kebocoran, infeksi dan komplikasi metabolic
i. Intake makanan tidak terganggu
4. Monitor masukan dan output cairan
j. Intake nutrisi tidak terganggu
5. Monitor kadar albumin, protein total, elektrolit, profil
k. Intake cairan tidak terganggu
lipid, glukosa darah, dan kimia darah
Setelah dilakukan tindakan keperawatan diharapkan terjadi 6. Monitor TTV
peningkatan status nutrisi : asupan makanan dan cairan dengan
kriteria hasil :

l. Asuhan makanan secara oral sebagian besar adekuat

m. Asupan cairan intravena
n. Asupan nutrisi parental sepenuhnya kuat
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 Infographic Style
NO.1 Presentation
Get a modern PowerPoint Presentation that is beautifully designed. Easy to change colors, photos and Text.
You can simply impress your audience and add a unique zing and appeal to your Presentations. I hope and I
believe that this Template will your Time, Money and Reputation. Get a modern PowerPoint Presentation that is
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06 05 04 03 02 01

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01 PowerPoint Presentation
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that this Template will your Time, Money and Reputation.
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02 PowerPoint Presentation
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THANK YOU
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 Fully Editable Icon Sets: C

You can Resize without

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