Burn Unitfix

7/26/2019 Burn Unitfix

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LAPORAN KASUS

ASUHAN KEPERAWATAN PADA NY. “A”

DENGAN NYERI AKUT DAN KERUSAKAN MOBILITAS FISIK PADA DIAGNOSA

MEDIS COMBUSTIO GRADE II AB 25% DI RUANG BURN UNIT RSUP SANGLAHDENPASAR

TANGGAL 27-29 NOEMBER 2!"#

I. PENGKA$IANT&''( )*+, 27 O,/01 2!"#

$) )*+, "7."5 34

R+&'& B+& +&4

D4'&/* )14* C/)0+*4/ '1 II AB 25% N/. RM "#!256"#

T&''( 1&',84& 27 N/1)01 2!"#

R+): *,4 RSUP SANGLAHA. I1&4*

". K(41&

N) N;. “A”U)+ #" :

$1&4* ,1()4& 11)+&

A') H4&+

P1&44,& SMAP1,18& P1'34 S3*

A() T0&&

2. P1&&''+&' 830

N) T&. “D”

U)+ ## :$1&4* ,1()4& (,4-(,4

A') H4&+

P1&44,& SMAP1,18& P/(4*4

A() T0&&

H+0+&'& 1&'& ,(41& S+)4 K(41&

B. RIWAYAT KESEHATAN

". K1(+:& U) L+, 0, 38:< ,1+ (1&'& & ,1+

+&''+&' ,,4



2. K1(+:& S D4,84 ,(41& )1&',& &;14 ,1+ (1&'&< &;14

4*,& :4(&' 4)0+( 1&'& *1&**4 14: & 10,< &;14 ;&'

4*,& *,( # =!-"!> & 01)0: * ,(41& 01'1, 1+)

* 8(&<* 13& (+, & *11(: 13& (+, 1&'& *,(

&;14 5 =!-"!>. K(41& 8+' )1&',& 4, 04* ),&< )&4< BAB +

BAK *1&44 ,1& ,1+ (1&'& ,(41& 410& & 1* ,,+ *

4'1,,,&.

#. R43; P1&;,4 S1,&' K(41& )1&',& &''( 27 /,/01

2!"# +,+( !7.!! 34< ,(41& )1&'()4 (+, 0, 438:< < ,1+

(1&'& & 1(, ,,4 01*) &,&; ;&' 4*100,& /(1: (1,&

,/)/ '* LPG. K(41& ,1)+4& 403 /(1: ,1(+'&; ,1 RSU

T0&& & )1& 4&,& 1)014& (+, & 1)*&'& 4&?+*1

*101(+) ,:4&; 4+8+, ,1 IGD RSUP S&'(:. K(41& 40 4 RSUP

S&'(: +,+( "".5! 34 & *1(&8+&; )1&,& 1041)1& (+,<

1)*&'& IUFD ,,4 ,&& 1&'& @4& RL 4 '/8/' & 1)*&'& ?/((; ,11 +,+& F". K(41& 8+' )1(,+,& /&'1&

:/ ,1& 4 ,:34,& )1&'()4 +) 4&:(*4< *11(: ,/&4*4

,(41& *04( 1&'& ,1*& @/)/* )1&4* GCS=E6M5>< 1?(1, +4(

< TD""!!< N6< RR2!< S#/<((+ ,(41& 44&:,& ,1 B+&

U&4. P &''( # &/1)01 2!"# ,(41& )1&'()4 /1*4 1)

+&+, 1)01*4:& 84&'& )4< *1)4&''+ ,1)+4& &''( "!

&/1)01 2!"# ,(41& )1&'()4 /1*4 ,1+ +&+, 4(,+,& *,4& '?

1&'& )1&')04( 84&'& ,+(4 4 1: : ,&& ,(41&.

6. R43; P1&;,4 D:+(+ K(41& )1&',& 4 4, 1&: )1&'()4

1&;,4 01 *114 :411&*4< ''( '4&8(< DM & *). K(41& 8+')1&',& 4, 1&: )1&'()4 1&;,4 *114 * 4&4 *101(+)&;.

K(41& 8+' )1&',& 4, )1)+&;4 43; (1'4 1: ),&&

& /0-/0&.

5. R43; P1&;,4 K1(+' ,(41& )1&',& 4,1(+'&; 4,

;&' )1&14 1&;,4 01 *114 DM< ''( '4&8(< :411&*4

)++& 1&;,4 ;&' 414 ,(41& * 4&4.

. R43; K1*1:& L4&',+&'& ,(41& )1&',& 4 4&''( 4

(4&',+&'& ;&' @+,+ 8+: 4 8(& ;. 1&4(*4 +): @+,+ 04,.

C. K10+:& B4/-P*4,/*/*4(-S44+(

".P/( R1*4*4

S101(+) *,4 ,(41& )1&',& 01&?* 1&'& 04,< 4, '&''+& 1&?*

*114 *1*, &?*< 0+,< &;14 <



S *,4 ,(41& )1&',& 01&?* 1&'& 04,< 4, '&''+& 1&?* *114

*1*, &?*< 0+,< &;14 <

2. P/( E(4)4&*4

S101(+) *,4 ,(41& )1&',& BAB " ,(4 *1:4 1&'& 3,+ ;&' 4, 1&+ 1&'&,/&*4*1&*4 (1)01,< 3& ,+&4&' & 0+ ,:* ?1@1*. K(41& )1&',& BAK 5- ,(4 1:4

1&'& 3& ,+&4&' 81&4: & 0+ ,:* +4&1.

S *,4 ,(41& )1&',& BAB " ,(4 *1:4 1&'& 3,+ ;&' 4, 1&+ 1&'&

,/&*4*1&*4 (1)01,< 3& ,+&4&' & 0+ ,:* ?1@1*. K(41& )1&',& BAK 5- ,(4 1:4

1&'& 3& ,+&4&' 81&4: & 0+ ,:* +4&1.

#. P/( N+4*4

S101(+) *,4 ,((41& )1&',& ),& # ,(4 *1:4 1&'& /*4 *+ 44&' &*4 (1&',

1&'& (+, +, & )4&+) 4 +4: - '1(* *1:4< 1&'& '1(* +,+& 2!! @@.

S *,4 ,(41& )1&',& ),& # ,(4 *1:4 1&'& /*4 *+ 44&' &*4 14

),&&&; 1*10+ 401(4,& /(1: *+)4&; 4(+ RS. K(41& )1&',& &?*+ ),& 04,

& 4 *1((+ )1&':04*,& *+ /*4 ),&& ;&' 401(4,& *+)4&;.

6. P/( I*4: T4+

S101(+) *,4 ,(41& )1&',& 04* 4+ -7 8) () *1:4< )() :4 & " 8)

*4&' :4. K(41& )1&',& 4, )*(: 1&'& 4*4: 4+&;.

S *,4 ,(41& )1&',& 4+ 1&'& &;1&;, 8) )() :4 & " 8) *4&' :4. K(41& 4, )1&'()4 '&''+& 4+.

5. /( P1*/&( H;'41&1

S101(+) *,4 ,(41& )1&',& 04* )&4 2 ,(4 *1:4 '4 & */1 :4< '/*/, '4'4

* )&4< ,1)* 2 ,(4 *1)4&''+ & '&4 08+ "-2 ,(4 *1:4.

S *,4 ,41& )1&',& 4, 1&: )&4 14 *1((+ 4 ( /(1: *+)4&; 1&'&

:&+, 0*: & 4 '&4,& 08+ 2 *1:4

. /( ,4?4* (4:&

S101(+) *,4 ,(41& )1&',& 4 01,44* 1&'& 04,< 4 )1(,+,&

,4?4* *114 )&4< ),&< & 0&+& /&' (4&.



S101(+) *,4 ,(41& )1&',& 4, 01,4?4 & 01,18< )1&8(&,& +'* *10'4

4*4 & 40+ *1 1)1&+:& ,44*&; *114 ),&< BAB< BAK 4 0&+ /(1: *+)4&;

7. /( */@4( & ,/)+&4,*4

S101(+) *,4 ,(41& )1&',& ))+ 014&1,*4< & 01,/)+&4,*4 1&'& 04, 4(4&',+&'& ,1(+'< )*;,< & (4&',+&'& ,18&;.

S *,4 ,(41& )1&',& 4 :&; 01,/)+&4,*4 & 014&1,*4 1&'& ,1(+'< ++&

1)& ;&' )1&81&'+,&; *1 1&'& 1+'* ,1*1:& ;& )13&;.

PEMERIKSAAN PENUN$ANG

P1)14,*& (0/+4+) =22""2!"# !9!7 )>

#. ;1 * 14 = '( !6""2!"#>

Test result satuan

A(0+)4& 2<27 '(

C14&4& !<5 )'(

SGPT 27< +L

SGOT 27<7 +L

BUN L )'(

N "62 ))/((

K 6<75 ))/((

C( "!#<" ))/((

P1)14,*& :/ ?// &14/ /*14/

C/ 01* & 01&+, &/)(



P+()/ , ), 4&?4(1 &/+(< '1,& 0/&@:/

S4&+* (1+ ,&& ,44 8)

D4?') ,&& ,44 &/)(

T+(&' +(&' ),, ,1(4&&

K1*& * 4&4 @// & +()/ 4, ), ,1(4&& = 4, +) 4&:(*4>

D. 1)14,*&& ?4*4,

K1& +)+) S1&'

K1*& C/)/* M1&4*

GCS E6< 5< M

TT TD ""!! ))H'

N 92)1&4

S #<@

RR ")1&4

D. PEMERIKSAAN HEAD TO TOES

NO ORGAN INSPEKSI PALPASI PERKUSI AUSKULTASI



"

2

#

6

K1(

W8:

M

M+(+

T1(4&'

4, 01&8/(&

1 (+, 0,

'1 II A ;&'

*+: )1)04,

= ?*1 '&+(*4 >

(+, ),

)/&'14&'

*4)14*< 4,

(1*4< 1?(1, +4( 4*/,/ )

,&& & ,44

,/&8+&'4 4,

&1)4*< 4,

01&8/(&

*4)14*< )+,/*

0404 (1)00< 0404

4, *4&/*4*<

4, ,41*

'4'4

*4)14* 4,

(1*4< 4,

*1+)1&

*4)14*< 4,

(1*4< 4,

1)01*& 1&

8+'+(4* &

,1(1&8 4/4

4, &;14

1,&<

T4, &;141,&

4, &;14

1,&<

4,

&;14 1,&

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01&8/(&

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01&8/(&

4, &;14

-

-

-

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L1:1

D

A0/)1&

*4)14*< 1

01,* (+, ;&'

)1)1: 0101&+,

< '1,& 4&4&' *4)14*< 4,

L1*4< 4,

4,&

*4)14*< 4,

84&'& +<

4, (1*4<

,(41& 4,

1*&' ,11

1 (+, 0,

(1&'& ,&&

1& & 01(,&'

'1 IIB *10&;, 7% (1&'&

,44< 01(,&' '1

II A 7%

(1&'& ,&& *+:

*+: 4(,+,&

*,4& '? & (+,

1,&< 4,

01&8/(&

4,

1&/&8/(&

+)04(4@+* 4,

&;14 1,&<

4, 4*1&*4

0/)1&

&;14 * 4

1,& CRT J 2

4)&4 4

*1(++:

(&'

0/)1&

1*4,+(1 4

*1(++: (&'

+ ,&& &

,44

04*4&' +*+

"!)1&4



G1&1(4

E,*1)4*

*

E,*1)4* 03:

,1)1:&

0 +&''+&

,,4 1 (+, 0, '1 II A

)*4&'-)*4&' " %

,,4 ,&&

& ,44 (+, ()

?*1 '&+(*4<

4, ?+*

14,



T+) 4&:(*4 (+, 0, () +&'& 1++

R1*+*4*4 @4& (+* (+, & 18 (+, 0,

H41/*4

H41/4, 184 ,& )1)4(4,4



II. DIAGNOSA KEPEAWATAN

A. A&(4* D

D D E4/(/'4 P/0(1)

" DS ,(41& )1&',& &;14

,1+ (1&'&< &;14 ;&' 4*,&

:4(&' 4)0+( 1&'& *1&**4 14: &

10,< &;14 ;&' 4*,&

*,( # = !-"! > & 01)0: *

,(41& 01'1, 1+) * 8(&

13& (+, & *11(: 13&

(+,

DO ,(41& ), )14&'4* *

)1&''1,& (1&'&&;. L+,

1: 1,*1)4* * & 4&''&'

,,4 ,&& & ,44 TT TD ""!!

))H' S #< C N )1&4 RR

2!)1&4

L+, 0,<

,1+*,& ,+(4<

&;14 ,+

&;14 ,+

2 DS ,(41& )1&',& 1 (+,

(1&'&< +&''+&' ,,4 ;&'

)*4: 40(+.

DO ), (+, ,1+ (1&'&

& ,1+ +&''+&' ,,4

T), (+, 38: ;&'

)/&'14&'

S #< C

L+, 0,

04/(/'4* ,1+*,&

,+(4 84&'&

10+,

1*4,/ 4&''4 4&?1,*4

# DS ,(41& )1&',& 4, 04*

),&< )&4< BABBAK *1&44

L+, 0, K1+*,&



,1& ,1+ (1&'&&; & ,,4&;

4 10& & 1* ,,+ * 4

'1,,& & 1* &;14

DO ,(41& 4 0&+ * ,1 ,)

)&4 /(1: *+)4&; ,(41& 4*+ *),& ,(41& 4)&4,& /(1: 13

'&''+&

&1+/)+*,+(1

&;14 ,+ &

1&++&&

,1*& ,1,+&

//

)/04(4* ?4*4,

B. R+)+*& D4'&/*

". N;14 ,+ 0 ,1+*,& ,+(4 4&4 1&'& ,(41& )1&',& &;14 ,1+

(1&'&< &;14 ;&' 4*,& :4(&' 4)0+( 1&'& *1&**4 14: & 10,< &;14

;&' 4*,& *,( # =!-"!> & 01)0: * ,(41& 01'1, 1+) *

13& (+, &. *11(: 13& (+,. K(41& ), )14&'4* *

)1&''1,,& (1&'&&;. L+, 1: 1,*1)4* * & +&''+&' ,,4

,&& & ,44 TT TD ""!! ))H'< S #< C< N )1&4< RR 2!

)1&4

2. R1*4,/ 4&''4 4&?1,*4 0 84,&'& ;&' 10+, 4&4 1&'& ,(41& )1&',&

1 (+, (1&'& +&''+&' ,,4 ;&' )*4: 4 0(+. T), (+,

,1+ (1&'& & ,1+ +&''+&' ,,4< ), (+, 38: ;&' )/&'14&'< S

#< C< WBC 9<###. K1+*,& )/04(4* ?4*4, 0 &;14 ,+, & 1&++&& ,1,+& // 4&4

1&'& ,(41& )1&',& 4, 04* ),&< )&4< BAKBAB *1&44 ,1& ,1+

(1&'& & & ,,4&; 410& & 1* ,,+ * 4'1,,& 1* &;14< ,(41&

40&+ * ,1 ,) )&4 /(1: *+)4&;< ,(41& 4*+ * ),&< ,(41& 4

)&4,& /(1: 13.

III. INTERERSI KEPERAWATAN

A. P4/4* M*(:

". N;14 ,+



2. R1*4,/ 4&''4 4&?1,*4

#. K1+*,& )/04(4* ?4*4,

B. I&11&*4

N) N; “A ” N/ RM

U)+ #" :+&

D H4

T'(

T+8+& I&11&*4 R*4/&(

" R0

+

27"

""#

T+8+& *11(:

4(,+,&

4&,&

,113&

*1() 226

8) 4:,&

&;14 1*4

1&'& @414

:*4(

. &;14

*,( ! = !-"!>

0. ,(41& 4,

)14&'4* *

4*1&+:

". K84 ,1(+:&&;14<

1:4,&

(/,*4,,1

& 4&1&*4* =!-"!>

2. $1(*,&

/*1+014, & 4&?/)*4

*14&' 1&'&

1,:+*+*&;

*1()

1041)1&(+,.

#. $1(*,&

/*1+014, & 4&?/)*4

*14&' 1&'&

1,:+*+*&;

*1()

1041)1&

(+,.

". &;14 *1((+ 010118 01&; ,11(40&

84&'& ,1+*,& 14

04*&; (4&' 01 *1()

1'&4& 0(+& &1041)1& 1+0:&

(/,*4,,1 4&1&*4*

&;14 )1&'41&4?4,*4184&; ,/)(4,*4

2. +,+&'& 1)4

)1)0&+ )1&':4(&',&

&;14 )1&4&',,&1(,**4< )1&'1:+4

;&' 4:,& )1)014,&

,1*1)& ,(41& +&+,)1&;4,& &

)1&4&',,& * @/&/(.

#. )1&4&',,& 1(,**4

)1&++&,& ,11'&'& //& ,1(1(:& +)+).

6. M1)?/,+*,& ,1)0(4 1:4& )1&4&',,&

1(,**4 & )1&4&',,&

* @/&/( ;&' )1&++&,& ,11'&+&'&



6. B14,&

4&,&,1&;)&&

* @/&/:

48&

1 ;&' ,*,4<

1+0:& /*4*4 ;&'

*14&'

5. D//&')1&''+&,&

1,&4,

)&81)1&*1**< @/&/:

1(,**4

/'1*4? &?*

()< 04)04&'&

4)84&*4

. K/(0/*41&'& 4)

)14* () 1)014&&('14,

?),/(/'4*.

5. )1)1@1 1&;1)0+:&

(+, ,(41&

. ' )1)1@1 /*1*

1&;1)0+:&

2 S11(:

4(,+,&

4&,&

,113&

*1() 226

8) 4:,&

&;14 1*4

1&'& @414

:*4(

". T4,

". P&+

1&)4(&

(+,

2. P&+ *+:+

+0+: ,(41&

#. B14,& 13& (+,

". +&+, )1&'1:+4 ,1)8+&

+ 1&;4)&'& = 4&?1,*4 >

& :*4( ;&' 4:,&2. 84, 1&4&',& *+:+

+0+: 41,4,& 1844&?1,*4

#. +&+, )1)1@1 1&;1)0+:& (+, *1

+&+, )1&8' (+, 1



&-&

4&?1,*4

2. L+,

)/&'14&'

#. WBC ()

0* &/)(

6. S,

)1&':4(&'

6. T1),&,(41&

+&' ,:+*+*<

'+&,& (4&1&

*1 ,4&*14(

,(41&

5. K/(0/*4

1)014&

&404/4@

*1*+4 4&4,*4

01*4: *1:4&'' 4, 184

4&?1,*4

6. 1,&4, *14( & 4&,&

,113& (4& )1(4&+&'4

*41& 1: 4&?1,*4

5. &404/4@ )1)0+&+:

)4,//'&4*)1 *1:4&''

)1&++&,& 1*4,/ 4&?1,*4

# T+8+& *11(:

4(,+,&

4&,&

,113&

*1() 226

8) 4:,&

'&''+&

)/04(4**4 01,+&'

1&'& @414

:*4(

". K(41&

))+

)1&''1,,&

,1

(1&'&&; *

018(& 2.K(41&

)1)1:&

,& +

)1&4&',,&

,1,+& &

?+&'*4 ;&'

". K84

,10++:&

,(41& ,& 1(;&& &

1(&

2. T1&+,&4&',

)/4*4 ,(41&

(),1))+&

,44*

#. I&*+,*4,&

& 0&+()

)/04(4*

@/&/: /&',3(,1 *1@

1

6. D//&' 4*4*4 &

". )1&'41&4?4,*4 )*(: &

)1)+:,& 4&11&*4

2. )1)1&'+:4 1&4(4&1: ,1))+& ,4?4*

#. )1&4&',,& ,1)&&

)/04(4**4

6. +&+, ,4? () 13&

,(41& & )1)014,& 14(104:



*,4 0&+&

,1(+' /&' 11,

()

)/04(4**4

,(41&5. M*+,,&

,4?4**1:4-:4

() 14

?4*4,

. K84

1,1)0&'&

,1))+&,(41&

5. ,/)+&4,*4 ,4? ;&')1&':*4(,& 104,& :*4(

1&'& )1&4&',,& 1?1,

)*4&'-)*4&'

. R*4/&( )1&'1:+4

1,1)0&'& ,1))+&)/04(4**4 ,(41& +&+,

4&11&*4 *1(&8+&;.

IV. IMPLEMENTASI KEPERAWATAN

N) N;. “A” N/. RM U)+ 67 :+&

N/ D H4&''(

8)

I)(1)1&*4 R1*/&:*4( P?



" I R0+ <

27""2!"#

2!.!!WITA

". M1&',84 K1&

+)+).

2. M1&'/0*1*4 TT

4 # 8)

#. M1&@+@4 &'&

*101(+) & *1*+:,/&, 1&'&

*41&.

6. M1&',84 +,+&<

3&< ,1& (+,

,/&4*4 *1,4 (+,

5. M1&'8,& 1,&4,

1(,**4 &?*

()

. . E(+*4

,11?1,4?&&;.

A&8+,& &('1*4,

I 04( (+, 0,

(+*.

". K1& +)+)

*41& *1&'.

2. TD ""!!

))H' N 92 )1&4

RR 2!)1&4S #.@

*O2 9%

#. T&'& *+:

4@+@4 1&'&

01*4:6. U,+& (+, 0,

1+) 38: )*4: *)

&)+& *+:

,14&' &

013& )1:

)+5. P*41& ))+

)1(,+,& 1:&4,

&* ().6. K(41& )1&',&

)*4: &;14

&', # *,( =!-

"!> P*41&

4014,&

@1)/(.



2 II R0+ <

"6"!2!"#

"!.!! WITA

". M1&',84 +,+&<

3&< & (+,

,/&4*4 4*1,4 (+,

2. M1)&+ *+:+ +0+:

,(41&

#. M1&',84 &;

&-& 4&?1,*4

6. M1&''+&,& *1(4)+

:&' & (4&1& *14(

5. B1,/(0/*4 ()

1)014& 1*4

*1*+4 4&4,*4

". U,+& (+, 0,

1+)

(1&'& & 38:<

(+, &',(

,/&4*4 4*1,4

(+, 04, (+,

), )1&'14&'

2. S+:+ +0+: ,(41&

#<@

#. D/(/ 1* &;14

* (+, 4*1&+:

& 04( 01'1,

C(/ S #7@R+0/ ),

,1)1:&

(+, 4(1&'& &

,,4 ,(41&

T+)/ 4,

184 1)01*&

84&'&

P+&*4/ (*1 6. K(41& )1*

&;)& 1&'&

*1(4)+ :&' &

(4&1& *14(

5. K(41& 4014,&

14 /( & 4



# III R0+ <

"6"!2!"#

"".!! WITA

". M1&',84 ,10++:&

,(41& 1&&'

1(;&& &

1(&2. M1&1&+,& 4&',

)/4*4 ,(41& ()

,1))+& ,4?4*

#. M1(4: ROM

&'& ,&& ,(41&

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