ASUHAN KEPERAWATAN

PADA PASIEN Tn. G

DENGAN DIAGNOSA CVA INFARK (STROKE)
DI RUANG ABIMANYU RSUD JOMBANG

DEPARTEMEN

KEPERAWATAN MEDIKAL BEDAH

Disusun Oleh:

...............................................

PROGRAM STUDI DIII KEPERAWATAN

SEKOLAH TINGGI ILMU KESEHATAN
INSAN CENDEKIA MEDIKA
JOMBANG
2019
 KEPERAWATAN MEDIKAL BEDAH
PROGRAM STUDI DIII KEPERAWATAN
SEKOLAH TINGGI ILMU KESEHATAN
INSAN CENDEKIA MEDIKA JOMBANG
Jl. Kemuning No. 57 A Candimulyo Jombang, Telp. 0321-8494886
Email: [email protected]

ASUHAN KEPERAWATAN PADA PASIEN Tn. G

DENGAN DIAGNOSA CVA INFARK (STROKE)
DI RUANG ABIMANYU RSUD JOMBANG

I. PENGKAJIAN
A. Tanggal Masuk :09 November 2021 (di ruang abimanyu)........................................
B. Jam masuk :19:43 WIB.......................................................................................
C. Tanggal Pengkajian :15 November 2021 (di ruang abimanyu)........................................
D. Jam Pengkajian : 15:30 WIB......................................................................................
E. No.RM :008562.............................................................................................
F. Identitas
1. Identitas pasien
a. Nama :Tn. G......................................................................................
b. Umur :69 Tahun................................................................................
c. Jenis kelamin :LAKI - LAKI.........................................................................
d. Agama :ISLAM...................................................................................
e. Pendidikan :S1...........................................................................................
f. Pekerjaan :PENSIUM..............................................................................
g. Alamat :Jl anggrek Gg 1 NO 11 CANDI MULYO JOMBANG........
h. Status Pernikahan : SUDAH KAWIN..................................................................
2. Penanggung Jawab Pasien
a. Nama :WIWIK..................................................................................
b. Umur :59 TAHUN............................................................................
c. Jenis kelamin :PEREMPUAN.......................................................................
d. Agama :ISLAM...................................................................................
e. Pendidikan :SMA.......................................................................................
f. Pekerjaan :IRT.........................................................................................
g. Alamat : Jl anggrek Gg 1 NO 11 CANDI MULYO JOMBANG.......
h. Hub. Dengan PX : ISTRI....................................................................................

G. Riwayat Kesehatan
1. Keluhan Utama
PENURUNAN KESADARAN
 2. Riwayat Kesehatan Sekarang
PENURURAN KESADARAN SEJAK KURANG DARI 5 HARI TIDAK BISA
BICARA DAN JALAN PASIEN MENGALAMI KEJANG, BATUK, SESAK NAFAS
3. Riwayat Kesehatan Dahulu
Keluarga mengatakan bahwa pasien pernah dirawat di rumah sakit lain beberapa minggu yang
lalu karena hipertensi. Sebelum d rujuk ke RSUD JOMBANG ...................................................
...........................................................................................................................................
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4. Riwayat Kesehatan Keluarga
KELUARGA PASIEN MENGATAKAN TIDAK ADA KETURUNAN.......................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
H. Pola Fungsi Kesehatan
1. Persepsi dan Pemeliharaan Kesehatan
a. Merokok : TIDAK MEROKO Jumlah : TIDAK ADAJenis:TIDAK
ADAKetergantungan: TIDAK ADA
b. Alkohol : TIDAK ADA Jumlah : TIDAK ADA Jenis: TIDAK ADA
Ketergantungan:TIDAK ADA
c. Obat-obatan : TIDAK ADA Jumlah : TIDAK ADA Jenis: TIDAK
ADA.Ketergantungan: TIDAK ADA
d. Alergi :TIDAK ADA..................................................................................................
e. Harapan dirawat di RS : LEKAS SEMBUH .............................................................
f. Pengetahuan tentang penyakit : PASIEN KURANG PAHAM..................................
g. Pengetahuan tentang keamanan dan keselamatan : TIDAK TERLALU PAHAM.....
h. Data lain : PASIEN TERPASANG NGT...................................................................
2. Nutrisi dan Metabolik
a. Jenis diet : MAKANAN YANG MENGANDUNG LEMAK TINGGI.....................
b. Diet/Pantangan : MAKANAN DAN MINUMAN ASEM.........................................
c. Jumlah porsi : ½ PORSI..............................................................................................
d. Nafsu makan : MENURUN........................................................................................
e. Kesulitan menelan : PASIEN MENGALAMI SUSAH MENELAN.........................
f. Jumlah cairan/minum : 5-6 GELAS PERHARI.........................................................
g. Jenis cairan : AIR PUTIH DAN SUSU......................................................................
h. Data lain : TIDAK ADA.............................................................................................
3. Aktivitas dan Latihan
Kemampuan perawatan diri 0 1 2 3 4
Makan/minum 2
Mandi 2
Toileting 2
Berpakaian 2
Berpindah 2
 Mobilisasi di tempat tidur & ambulasi ROM 2
0: Mandiri 2: Dibantu orang 4: Tergantung total
1: Menggunakan alat bantu 3: Dibantu orang lain dan alat
a. Alat bantu : Tidak ada.................................................................................................
b. Data lain : pasien terpasang kateter urin.....................................................................
4. Tidur dan Istirahat
a. Kebiasaan tidur : pasien tidur terlentang.....................................................................
b. Lama tidur: kurang dari 8 jam perhari........................................................................
c. Masalah tidur : ..........................................................................................................
d. Data lain : pasien mengalami tidur yang terganggua akibat kelemahan otot bagian
ekstremitas atas dan bawahdi sebelah kiri
5. Eliminasi
a. Kebiasaan defekasi : saat di RS px mengalami BAB 1 X SEHARI...........................
b. Pola defekasi : SAAT DI RUMAH PASIEN BAB 2X SEHARI...............................
c. Warna feses : AGAK KECOKLATAN......................................................................
d. Kolostomi :TIDAK ADA............................................................................................
e. Kebiasaan miksi :BAK SELAMA 4X SEHARI.........................................................
f. Pola miksi :SETIAP 3X SEHARI...............................................................................
g. Warna urine : KUNING PEKKAT.............................................................................
h. Jumlah urine : 400-500 CC SETIAp 24 jam...............................................................
i. Data lain :TIDAK ADA .............................................................................................
6. Pola Persepsi Diri (Konsep Diri)
a. Harga diri : BISA MENGENAL DIRINYA...............................................................
b. Peran : SEBAGIA KEPALA RUMAH TANGGA (AYAH).....................................
c. Identitas diri : BAIK...................................................................................................
d. Ideal diri : PASIEN TIDAK MERASA TAKU PADA PETUGA NAKES D RS
YANG MERAWATNYA...........................................................................................
e. Penampilan : BAIK.....................................................................................................
f. Koping : PASIEN PATUT PADA NAKES DAN ISTERINYA KETIKA MAU DI
RAWAT......................................................................................................................
g. Data lain : TIDAK ADA.............................................................................................
7. Peran dan Hubungan Sosial
a. Peran saat ini : SEBAGAI KEPALA RUMAH TANGGA
b. Penampilan peran : BAIK
c. Sistem pendukung : KELUARGA YANG SELALU MENDUKUNG UNTUK
KESEMBUHAN PX
d. Interaksi dengan orang lain : PASIENAMPU BERINTERAKASI DENGAN BAIK
e. Data lain : TIDAK ADA
8. Seksual dan Reproduksi
a. Frekuensi hubungan seksual : PASIEN SELAMA SAKIT TIDAK MEMIKIRKAN
TENTANG HUBUNGAN SEKSUAL
 b. Hambatan hubungan seksual : PASIEN MASI SAKIT
c. Periode menstruasi : TIDAK ADA
d. Masalah menstruasi : TIDAK ADA
e. Data lain :TIDAK ADA
9. Kognitif Perseptual
a. Keadaan mental : PASIEN BELUM SADAR PENUH..............................................
b. Berbicara : PASIEN MASI SUSAH UNTUK BERBICARA ..................................
c. Kemampuan memahami : PASIEN MASI KURANG MAMPU UNTUK
MEMAHAMI
d. Ansietas : PASIEN MENGALAMI STROKE DI SEBELAH EKSTERMITAS KIRI
.....................................................................................................................................
e. Pendengaran : pasien bisa mendengar jelas................................................................
f. Penglihatan : pasien bisa melihat dg jelas...................................................................
g. Nyeri : nyeri pada ekstermitas bagian kiri atas dan bawah.........................................
h. Data lain : tidak ada.....................................................................................................
10. Nilai dan Keyakinan
a. Agama yang dianut : islam..........................................................................................
b. Nilai/keyakinan terhadap penyakit : pasien sngat yakin pada penyakit yang di alami
.....................................................................................................................................
c. Data lain : tidak ada.....................................................................................................

I. Pengkajian
a. Vital Sign
Tekanan Darah :150/90................ Nadi : 90 x/t...................
Suhu :37,3 c................. RR : 26x/t...................
b. Kesadaran :kurang normal................................................
GCS :3 2 5 ...............................................................
c. Keadaan Umum
a. Status gizi : Gemuk Normal Kurus
Berat Badan :70 Kg................. Tinggi Badan :170 cm.............
b. Sikap : Tenang Gelisah Menahan nyeri
d. Pemeriksaan Fisik
1) Kepala
a. Warna rambut : putih............................................................................................
b. Kuantitas rambut : bagus.......................................................................................
c. Tekstur rambut : lembut........................................................................................
d. Kulit kepala :bagus................................................................................................
e. Bentuk kepala :simetris.........................................................................................
f. Data lain : .............................................................................................................
2) Mata
a. Konjungtiva : tidak ada.........................................................................................
b. Sclera : tidak ada...................................................................................................
 c. Reflek pupil : normal............................................................................................
d. Bola mata : normal................................................................................................
e. Data lain : tidak ada...............................................................................................
3) Telinga
a. Bentuk telinga : simetris.......................................................................................
b. Kesimetrisan : baik................................................................................................
c. Pengeluaran cairan : tidak ada...............................................................................
d. Data lain :tidak ada................................................................................................
4) Hidung dan Sinus
a. Bentuk hidung : mancung ....................................................................................
b. Warna : sawo matang............................................................................................
c. Data lain :tidak ada................................................................................................
5) Mulut dan tenggorokan
Bibir : lembab.............................................................................................................
Mukosa :lembab.........................................................................................................
Gigi :masi lengkap , ..................................................................................................
Lidah : normal ...........................................................................................................
Palatum :normal.........................................................................................................
Faring :normal............................................................................................................
Data lain :tidak ada.....................................................................................................
....................................................................................................................................
6) Leher
Bentuk : normal..........................................................................................................
Warna : sawo matang.................................................................................................
Posisi trakea : normal (ada di tengah)........................................................................
Pembesaran tiroid : tidak ada.....................................................................................
JVP : PR + 0 cmH2O.....................................................................................................
Data lain : tidak ada....................................................................................................
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7) Thorax
 Paru-Paru
a. Bentuk dada: normal......................................................................................
b. Frekuensi nafas :............................................................................................
c. Kedalaman nafas :..........................................................................................
d. Jenis pernafasan :...........................................................................................
e. Pola nafas : dalam dan dangkal......................................................................
f. Retraksi dada :................................................................................................
g. Irama nafas : Ronkhi......................................................................................
h. Ekspansi paru :...............................................................................................
i. Vocal fremitus :..............................................................................................
j. Nyeri : tidak ada.............................................................................................
 k. Batas paru :.....................................................................................................
l. Suara nafas :...................................................................................................
m. Suara tambahan :............................................................................................
n. Data lain :.......................................................................................................
 Jantung
a. Ictus cordis : tidak tampak.............................................................................
b. Nyeri :tidak ada..............................................................................................
c. Batas jantung : Normal Batas jantung kiri pada intercostal space (ICS) 4-6
linea midklavikularis kiri dan batas kanan jantung pada linea parasternalis
kanan. Batas atas jantung umumnya terdapat pada ICS 2 kanan linea
parasternalis kanan.
d. ........................................................................................................................
e. Bunyi jantung : normal S1 S2........................................................................
f. Suara tambahan : tidak ada............................................................................
g. Data lain :tidak ada.........................................................................................
8) Abdomen
a. Bentuk perut: normal............................................................................................
b. Warna kulit :sawo matang.....................................................................................
c. Lingkar perut 75 cm..............................................................................................
d. Bising usus : normal 12x/t....................................................................................
e. Massa :normal.......................................................................................................
f. Acites : Tidak ada penumpukan cairan pada abdomen.........................................
g. Nyeri :tidak ada.....................................................................................................
h. Data lain :tidak ada................................................................................................
9) Genetalia :
a. Kondisi meatus :normal........................................................................................
b. Kelainan skrotum : tidak ada.................................................................................
c. Odem vulva : tidak ada.........................................................................................
d. Kelainan :tidak ada................................................................................................
e. Data lain : tidak ada...............................................................................................
10) Ekstremitas
a. Kekuatan otot: Lemah
b. Turgor : normal ....................................................................................................
c. Odem : tidak ada...................................................................................................
d. Nyeri :di bagian ekstermitas atas dan bawah bagian kiri......................................
e. Warna kulit : sawo matang....................................................................................
f. Akral :...................................................................................................................
g. Sianosis : tidak ada................................................................................................
h. Parese :..................................................................................................................
i. Alat bantu : tidak ada............................................................................................
j. Data lain :tidak ada................................................................................................
e. Pemeriksaan Penunjang
Pemeriksaan laboratorium
Tgl d terima : 16 November 2021 Pukul 09:21
Tgl selesai : 16 November 2021 Pukul 10:01...................................................................
PEMERIKSAAN HASIL NILAI NORMAL
Hb L 10,4 13,2-17,3 g/dl
Leukosit H 11,57 3,8-10,6 ^ /
Eritrosit L 3,26 4,4 – 5,9 10^
Trombosit H 444 150-440 10^
I/T Ratio 0,01 <0,02

Radiologi : Thorax ,Ct scan

f. Terapi Medik
PAMOL 1 gr
RANITIDIN 50 Mg
Fisioterapi .........................................................................................................................
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II. ANALISA DATA
NO. DATA ETIOLOGI MASALAH
1 S: keluaga pasien mengatakan penurunan KEPEKATAN Gangguan perfusi
kesadaran menurun DARAH jaringan serebral
O: - pasein tampak lemah MENINGKAT
GCS 3,2,5
Td160/200 Mmg
S: 37 C
N :96 Sirkulati serebral
RR : 22 Terganggu
SPO2 : 97%
Terpasang infus, NGT , kateter
Urin Penrunan Darah
dan O2 ke otak

Gangguan perfusi
jaringan serebral

III.DIAGNOSA KEPERAWATAN (SESUAI PRIORITAS)

1. Ketidakefektifan perfusi jaringan serebral berhubungan gangguan aliran arteri
 2. Gangguan mobilitas fisik.....................................................................................
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3. ....................................................................................................................................
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4. ....................................................................................................................................
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5. ....................................................................................................................................
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6. ....................................................................................................................................
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 IV. RENCANA TINDAKAN KEPERAWATAN

NO. DIAGNOSA NOC NIC

KEPERAWATAN (SMART)
Label NOC : Label NIC :

Indikator : Aktifitas Keperawatan :

Indeks
No. Indikator
1 2 3 4 5

V. IMPLEMENTASI
 NO. HARI/ JAM TINDAKAN KEPERAWATAN PARAF
DX TGL

VI. EVALUASI
NO. NO. DX HARI/ JAM EVALUASI PARAF
TGL