NAMA KELOMPOK

1Putri Ratna Sari

Firdha Aprianti
Riska S.
A. Mirnawati
ASUHAN KEPERAWATAN PADA Ny. S
DENGAN DIAGNOSA MEDIS DISPESIA
DALAM PEMENUHAN KEBUTUHAN RASA
NYAMAN DI RUMAH SAKIT UMUM
DAERAH MAKASSAR
1. PENGKAJIAN
A. IDENTITAS

1. IDENTITAS KLIEN
Nama : Ny. S
Tempat tanggal lahir/umur : 03 Agustus 1967
Pendidikan Terakhir : SLA
Agama : Islam
Suku : Jawa
Status Perkawinan : Menikah
Pekerjaan : Karyawana Swasta
TB/BB : 160/70 kg
Golongan Darah :-
Diagnosa Medis : Dispepsia
Gangguan KDM : Nyeri, bersihan nafas tidak efektif
Alamat :

2. IDENTITAS PENANGGUNG JAWAB

Nama : Tn. S
Umur : 57 Tahun
Pendidikan Terakhir : SLTA
Agama : Islam
Suku : Jawa
Hubungan Dengan Pasien : Suami
Pekerjaan : Karyawan Swasta
Alamat :
B. Riwayat Kesehatan
1. Keluhan Utama
Pasien mengatakan nyeri perut dan batuk

2. Riwayat Kesehatan Saat ini

Alasan masuk rumah sakit : Pasien mengatakan bahwa sejak 1 minggu yang
lalu merasakan nyeri di ulu hati, riwayat maag, Klien mengatakan nyerinya
timbul saat melakukan aktivitas, berdenyut-denyut dan hilang timbul, klien
mengatakan nyeri pada ulu hati, skala 5, waktu kurang lebih 5 menit, klien
mengataka merasa binggung dengan penyakitnya, merasa khawatir dengan
penyakit yang dihadapi, klien mengatakan sulit untuk berkonsentrasi, klien
merasa pusing, klien merasa mual dan muntah, merasa tidak berdaya karena
penyakit yang dialami dan kemudian merasa sesak terutama saat batuk, klien
mengatakan, klien mengatakan banyak lendir saat batuk, klien mengatakan
bahwa seperti ada dahak yang menghalangi nafas. Klien tampak meringis
menahan sakitnya, gelisah, tegang, pucat, sering memegang abdomen saat
merasa nyeri, merasa cemas, batuk tidak efektif, sputum berlebihan, terdengar
bunyi ronchi, pola napas berubah
Timbulnya keluhan : Mendadak. Keluarga mengatakan tidak melakukan apa-
apa untuk mengatasi sakitnya karena langsung dibawa kerumah sakit
3. Riwayat Kesehatan masa lalu
Klien mengatakan tidak mempunyai riwayat penyakit, klien mengataka tidak
memiliki riwayat kecelakaan sebelumnya, klie mengatakan tidak memiliki ri-
wayat dirawat sebelumnya, klien mengatakan tidak pernah dioperasi, klien
mentakan tidak memiliki alergi apapun, klie menagatakan tidak suka dan
jarang minum air putih dan vitamin.

4. Riwayat Kesehatan keluarga

Klien mengatakan tidak ada kebiasaan hidup tidak sehat dalam keluarga,
klien mengatakan tidak ada riwayat penyakit menular dikeluarganya, klien
mengataka tidak ada riwayat penyakit keturunan dikeluarganya
 PEMERIKSAAN FISIK
KEADAAN UMUM
TB/BB : 160 cm/70 kg
TD : 130/90 mmHg
Nadi : 94x/menit
Suhu : 38C
RR : 20x/menit
Kulit dan kuku : Bersih
Kepala dan rambut : Bersih dan tidak ada lesi
Mata : Tidak ada gangguan pengelihatan
Hidung : Bersih tidak ada lesi
Telinga : Tidak ada gangguan pendengaran
Bibir : Bibir tidak pecah, tidak ada sariawan/lesi
Dada (Paru-Paru)
Inspeksi : Tidak ada lesi, tidak ada edema, ekspansi dada simetris
Palpasi : Tidak ada nyeri tekan
Perkusi : Sonor
Auskultasi : Terdengar bunyi ronchi
Jantung : Tidak ada lesi, tidak ada nyeri tekan, suara pekak
Abdomen
Inspeksi : Tidak ada lesi, tidak ada edema
Auskultasi : Normal (16x/menit)
Perkusi : Timpani
Palpasi : Terdapat nyeri pada ulu hati bagian tengah atas perut
Klasifikasi Data
DS •
•
Klien mengatakan bahwa sejak 1 minggu yang lalu merasakan nyeri di ulu hati
Klien mengatakan nyeri saat melakukan aktifitas
• Klien mengatakan nyeri berdenyut-denyut dan hilang timbul
• Klien mengatakan nyeri pada bagian ulu hati
• Klien mengatakan skala 5
• Klien mengatakan waktunya kurang lebih 5 meit
• Klien mengatakan merasa binggung dengan penyakitnya
• Klien mengatakan merasa khawatir dengan penyakit yang dihadapi
• Klien mengatakan sulit untuk berkosentrasi
• Klien mengatakan sering pusing
• Klien mengatakan mual dan muntah
• Klien mengatakan merasa tidak berdaya karena penyakit yang dialami
• Klien mengatakan sesak terutama saat batuk
• Klien mengatakan banyak lendir saat batuk
• Klien mengatakan bahwa seperti ada dahak yang menghalangi nafas

DO •
•
Klien tampak meringis menahan sakitnya
Klien tampak gelisah
• • Klien tampak tegang
• Klien tampak pucat
• Terdengar bunyi ronchi
• Klien tampak sering memegang abdomen saat merasa nyeri
• Klien cemas
• TTV
TD : 130/90 mmHg
Nadi : 94x/menit
Suhu : 38C
RR : 20x/menit
• Batuk tidak efektif
• Sputum berlebihan
• Pola nafas berubah
 Analisa Data
Dx. 1 Nyeri Akut

Data Subejktif :
• Klien mengatakan bahwa sejak 1 minggu yang lalu merasakan nyeri di ulu hati
• Klien mengatakan nyeri saat melakukan aktifitas
• Klien mengatakan nyeri pada bagian ulu hati
• Klien mengatakan skala 5
• Klien mengatakan waktunya kurang lebih 5 menit

Data Objektif
• Klien tampak meringis menahan sakitnya
• Klien tampak gelisah
• Klien tampak sering memegang abdomen saat merasa nyeri
• TTV
TD : 130/90 mmHg
Nadi : 94x/menit
Suhu : 38.C
RR : 20x/menit
 Analisa Data
Dx. 2 Nausea

Data Subejktif :
• Klien mengatakan merasa binggung dengan penyakitnya
• Klien mengatakan merasa khawatir dengan penyakit yang dihadapi
• Klien mengatakan sulit untuk berkonsentrasi
• Klien mengatakan sering pusing
• Klien mengatakan mual dan muntah
• Klien mengatakan merasa tidak berdaya karena peyakit yang dialami
Data Objektif
• Klien tampak gelisah
• Klien tampak tegang
• Klien tampak pucat
• Klien tampak cemas

Dx. 3 Bersihan Jalan Napas Tidak Efektif

Data Subjektif
• Klien mengatakan sesak terutama saat batuk
• Klien mengatakan bahwa seperti ada dahak yang menghalangi nafas
• Klien mengatakan banyak lendir saat batuk
Data Objektif
• Batuk tidak efektif
• Terdengar bunyi ronchi
• Sputum berlebihan
• Pola napas berubah
Diagnosis Keperawatan

Nyeri akut berhubungan dengan iritasi mukosa lambung

Contents

Ansietas berhubugan dengan perubahan status kesehatan

Contents

Bersihan jalan nafas tidak efektif berhubungan dengan

sekresi yang tertahan

Contents
 INTERVENSI
DX. 1 Nyeri akut berhubungan dengan iritasi mukosa lambung

 SLKI (Luaran)
Setelah dilakuka tindakan keperawatan selama 3 x 24 jam. Di harapkan tingkat nyeri menurun
dengan kriteria hasil :
1. Keluhan nyeri menurun (5)
2. Meringis menurun (5)
3. Gelisah menurun (5)

 SIKI (Intervensi)
Observasi
• Identifikasi lokasi, karakteristik, durasi, frekuensi, kualitas, intensitas nyeri
• Idetifikasi skala nyeri
• Identifikasi factor yang memperberat dan memperingan nyeri
Terapeutik
• Berikan teknik nonfarmakologi untuk mengurangi rasa nyeri
Edukasi
• Jelaskan peyebab, periode, dan pemicu nyeri
• Jelaskan strategi meredahkan nyeri
Observasi
• Kolaborasi pemberian analgetik, jika perlu
 DX. 2 Ansietas berhubungan dengan perubahan status kesehatan

 SLKI (Luaran)
Setelah dilakukan tidakan keperawatan selama 3x24 jam diharapkan tingkat
ansietas meuru dengan kriteria hasil :
1. Verbalisasi kebigungan menurun (5)
2. Verbalisasi khawatir akibat kondisi yang di hadapi menurun (5)
3. Perilaku gelisah menuru (5)
4. Anoreksia menurun (5)
 SIKI (Intervensi) 5. Pucat menurun (5)
Observasi
• Identifikasi penuruan tingkat energi, ketidakmampuan
berkonsentrasi atau gejala lai yang menggangu
kemampuan kongnitif
Terapeutik
• Ciptakan lingkungan tenang dan tanpa gangguan
dengan pencahayaan da suhu ruang nyaman, jika
memungkinkan
• Berikan informasi tertulis tentang persiapan dan
prosedur teknik relaksasi
• Gunaka suara lembut dengan irama lambat dan
berirama
Edukasi
• Jelaskan tujuan, manfaat, batasan, dan jenis relaksasi
yang tersedia (mis. Musik, meditasi, apas dalam,
relaksasi otot progresif
DX. 3 Bersihan jalan nafas tidak efektif berhubungan dengan sekresi yang tertahan

SLKI (Luaran)
Setelah dilakukan tindakan keper- SIKI (Luaran)
awatan selama 1x24 jam diharap-
kan bersuhan jalan napas
meningkat dengan kriteria hasil : Observasi
1. Batuk efektif meningkat (5) • Identifikasi kemampuan batuk
• Monitor adanya retensi sputum
2. Produksi sputum menurun (5)
3. Gelisah menurun (5) Terapeutik
• Atur posisi semi-Fowler atau Fowler
4. Frekuensi napas membaik (5) • Pasang perlak dan bengkok di pangkuan pasien

Edukasi
• Jelaskan tujuan dari prosedur batuk efektif
• Ajurkan tarik nafas dalam melalui hidung selam 4 detik, ditahan selam 2
detik, kemudian keluarkan dari mulut denga bibir mencucu (dibulatkan)
selama 8 detik
• Anjurkan mengulangi tarik napas dalam higga 3 kali
• Anjurkan batuk dengan kuat langsung setelah tarik napas dalam ke-3
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