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LAPORAN RESUME KLIEN Nama Mahasiswa



: Suryadi Fahrin, S.Kep



NIM



: 1630913310039



Kelompok



:C



Tanggal Praktek/Minggu ke : 10-15 Juli 2017/ IX Tanggal/Jam Pengkajian



1. Identitas Pasien: Nama Umur Jenis Kelamin Alamat Pendidikan Terakhir Suku Agama Status Perkawinan Pekerjaan No. Rekam Medik Diagnosis Medis



: 11 Juli 2017/22.00 Tanggal/Jam MRS : -



: Tn. A : 80 th : Laki-Laki : Jl. Mahligai : S1 : Banjar : Islam : Menikah : Pensiunan : 10-70-xx : HF



2. Alasan Masuk (Keluhan Utama) : Alasan masuk pasien adalah pasien mengeluhkan sesak nafas dan saat bernafas merasa tidak puas, jantung berdebar-debar. .............................................................................................................................. 3. Riwayat Penyakit: Sebelumnya pasien pernah mengalami TB dan pengobatan OAT 6 bulan dan sudah tuntas 1 tahun lalu, klien juga mempunyai riwayat tidak bisa beraktivitas dan akan menimbulkan sesak



4. Pengobatan yang didapat saat ini furosemide, 02 4lpm, po Aspilet



5. Analisis Data Data Data Obyektif



Data Subyektif



 Pasien terlihat sesak saat bernafas



 Pasin mengeluh sesak  Pasien mengatakan sesak bertambah saat beraktivitas dan saat tidur terlentang



Etiologi



Masalah



Nyeri (dada) ………………… ………………… ………………… ………………… …………………



Gangguan Pola Nafas …………………… …………………… …………………… ……………………



Diagnosis Keperawatan 1. Gangguan Pola Nafas b.d Nyeri (dada)



Rencana Asuhan Keperawatan NOC NIC Setelah dilakukan tindakan keperawatan selama 3 Terapi Oksigen x 24 jam diharapkan klie dapat melakukan 1. Bersihkan mulut, hidung, dan seckret trakea aktivitas dengan kriteria hasil : 2. Pertahankan jalan napas yang paten - tidak ada sianosis dan dyspneu (mampu 3. Monitor aliran oksigen mengeluarkan sputum, mampu bernapas 4. Pertahankan posisi klien dengan mudah) 5. Monitor TD, nadi, dan RR - Menunjukkan jalan nafas yang paten (frekuensi pernafasan rentang normal, tidak ada suara nafas abnormal) - Tanda-tanda vital dalam rentang normal .............................................................................................................................. .............................................................................................................................. .......................................................................................................................... .... .............................................................................................................................. Implementasi .............................................................................................................................. No. Dx Hari/tanggal/jam Tindakan .............................................................................................................................. 1. Bersihkan.... mulut, hidung, dan seckret 1. Selasa 11 Juli 2017/22.00 WITA .......................................................................................................................... trakea .............................................................................................................................. 2. Pertahankan jalan napas yang paten .......................................................................................................................... .... oksigen 3. Monitor aliran .............................................................................................................................. 4. Pertahankan posisi klien .......................................................................................................................... .... nadi, dan RR 5. Monitor TD, .............................................................................................................................. .............................................................................................................................. .......................................................................................................................... .... .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .......................................................................................................................... .... .............................................................................................................................. .............................................................................................................................. .......................................................................................................................... .... .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .......................................................................................................................... .... .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .......................................................................................................................... .... .............................................................................................................................. .............................................................................................................................. .......................................................................................................................... .... .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. ..............................................................................................................................



Catatan Perkembangan S : Pasien mengatakan nyaman saat bernafas O : Pasien dapat bernafas normal Tanda vital dalam keadaan normal A : Masalah teratasi P : Intervensi dihentikan .............................................................................................................................. ..............................................................................................................................



Banjarmasin, 11 Juli 2017 Mahasiswa,



(Suryadi Fahrin, S.Kep)