tag:blogger.com,1999:blog-22282998289020521632024-02-07T11:39:22.439-08:00Erfansyah. HRBlog Kumpulan Asuhan Keperawatan
Program Profesi STIKes ALMA ATA YOGYAKARTAERFANSYAH. HRhttp://www.blogger.com/profile/07497970584312798191noreply@blogger.comBlogger493125tag:blogger.com,1999:blog-2228299828902052163.post-59385486541450085832013-06-22T08:37:00.001-07:002013-06-22T08:37:49.169-07:00MAKALAH ASUHAN KEPERAWATAN PADA NY. H DENGAN STROKE HEMORAGIC DI RUANG ICU<!--[if !mso]>
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<div class="WordSection1">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b><span style="mso-ansi-language: IN; mso-fareast-language: IN;">MAKALAH</span></b></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b><span style="mso-ansi-language: IN; mso-fareast-language: IN;">ASUHAN KEPERAWATAN </span></b><b><span lang="EN-US" style="mso-fareast-language: IN;">P</span></b><b><span style="mso-ansi-language: IN; mso-fareast-language: IN;">ADA</span></b><b><span lang="EN-US" style="mso-fareast-language: IN;"></span></b></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b><span style="mso-ansi-language: IN; mso-fareast-language: IN;">NY. H DENGAN STROKE
HEMORAGIC </span></b><b><span lang="EN-US" style="mso-fareast-language: IN;">DI</span></b><b><span style="mso-ansi-language: IN; mso-fareast-language: IN;"> RUANG ICU RSUD </span></b></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b><span style="mso-ansi-language: IN; mso-fareast-language: IN;">SARAS HUSADA PURWOREJO</span></b></div>
<div align="center" class="MsoNormal" style="text-align: center;">
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<br /></div>
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<br /></div>
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<br /></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="mso-ansi-language: IN; mso-fareast-language: IN; mso-no-proof: yes;">
</span><u><span style="mso-ansi-language: IN;"></span></u></div>
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<br /></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Disusun oleh :</span></b></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
<div align="center" class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><u><span style="mso-ansi-language: IN;">ERFANSYAH</span></u></b></div>
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">120300036</span></b></div>
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><u><span style="mso-ansi-language: IN;">NURUL HIDAYAH</span></u></b></div>
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">120300058</span></b></div>
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><u><span style="mso-ansi-language: IN;">SITI SUWARSIH</span></u></b></div>
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">120300063</span></b></div>
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><u><span style="mso-ansi-language: IN;">PRIMA AGUSTIN W</span></u></b></div>
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">120300072</span></b></div>
<div align="center" class="MsoNormal" style="text-align: center;">
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<b style="mso-bidi-font-weight: normal;"><span style="font-size: 14.0pt; line-height: 150%; mso-ansi-language: IN;">STIKES</span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-size: 14.0pt; line-height: 150%;"> ALMA ATA</span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-size: 14.0pt; line-height: 150%; mso-ansi-language: IN;"> </span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-size: 14.0pt; line-height: 150%;">YOGYAKARTA</span></b><b style="mso-bidi-font-weight: normal;"><span style="font-size: 14.0pt; line-height: 150%; mso-ansi-language: IN;"></span></b></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span style="font-size: 14.0pt; line-height: 150%; mso-ansi-language: IN;">PROGRAM STUDY NERS JURUSAN PENDIDIKAN NERS</span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-size: 14.0pt; line-height: 150%;"></span></b></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-size: 14.0pt; line-height: 150%;">201</span></b><b style="mso-bidi-font-weight: normal;"><span style="font-size: 14.0pt; line-height: 150%; mso-ansi-language: IN;">3</span></b></div>
<div align="center" class="MsoNormal" style="line-height: 200%; text-align: center;">
<b><span lang="SV" style="mso-ansi-language: SV;">KATA PENGANTAR</span></b></div>
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<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span lang="SV" style="mso-ansi-language: SV;">Alhamdulillah hirrobbil
a’lamin segala puji bagi Allah Tuhan semesta alam penulis panjatkan , karena
atas rahmat dan karunianya penulis dapat menyelesaikan </span><span style="mso-ansi-language: IN;">makalah</span><span lang="SV" style="mso-ansi-language: SV;"> dengan judul ” Asuhan Keperawatan Pada Klien </span><span style="mso-ansi-language: IN;">Ny. </span><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-spacerun: yes;"> </span>”</span><span style="mso-ansi-language: IN;">H</span><span lang="SV" style="mso-ansi-language: SV;">” </span><span style="mso-ansi-language: IN;">Dengan </span><span lang="SV" style="mso-ansi-language: SV;">Diagnosa </span><span style="mso-ansi-language: IN;">Stroke Hemoragic</span><span lang="SV" style="mso-ansi-language: SV;"> Di Ruangan </span><span style="mso-ansi-language: IN;">ICU RSUD Saras Husada Purworejo</span><span lang="SV" style="mso-ansi-language: SV;">”.</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span lang="SV" style="mso-ansi-language: SV;">Dalam penulisan makalah ini
penulis menemukan kesulitan, Namun berkat bantuan, bimbingan dan pengarahan
dari berbagai pihak akhirnya<span style="mso-spacerun: yes;"> </span>penulis
dapat menyelesaikan </span><span style="mso-ansi-language: IN;">makalah</span><span lang="SV" style="mso-ansi-language: SV;"> ini sesuai dengan waktu yang diberikan.
Untuk itu pada kesempatan ini dengan segala kerendahan hati izinkanlah saya
untuk menyampaikan penghargaan dan rasa terima kasih kepada yang terhormat :</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt; mso-list: l17 level1 lfo109; tab-stops: list 56.6pt; text-align: justify; text-indent: -22.5pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="DA" style="mso-ansi-language: DA;">Drg.
Gustanul Arifin, M.Kes selaku Direktur RSUD Saras Husada Purworejo.</span><span lang="EN-US"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt; mso-list: l17 level1 lfo109; tab-stops: list 56.6pt; text-align: justify; text-indent: -22.5pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="mso-ansi-language: IN;">Ibuk Sunarsih
S.Kep, Ns Selaku Koordinator Stase Gawat Darurat STIKES Alma Ata Yogyakarta</span><span lang="EN-US"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt; mso-list: l17 level1 lfo109; tab-stops: list 56.6pt; text-align: justify; text-indent: -22.5pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="mso-ansi-language: IN;">BapakWidodo
SA, S.Kep Ns, MM Selaku Pembimbing Ruang IGD Rumah Sakit Umum Daerah Saras
Husada Purworejo</span><span lang="EN-US"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt; mso-list: l17 level1 lfo109; tab-stops: list 56.6pt; text-align: justify; text-indent: -22.5pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="mso-ansi-language: IN;">IbukRuwiyah,
S.Kep Ns, Selaku Pembimbing Ruang ICU Rumah Sakit Umum Daerah Saras Husada
Purworejo</span><span lang="EN-US"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt; mso-list: l17 level1 lfo109; tab-stops: list 56.6pt; text-align: justify; text-indent: -22.5pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="mso-ansi-language: IN;">Ibuk Nur
Faizah, AMK Selaku Pembimbing Ruang ICU Rumah Sakit Umum Daerah Saras Husada
Purworejo</span><span lang="EN-US"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt; mso-list: l17 level1 lfo109; tab-stops: list 56.6pt; text-align: justify; text-indent: -22.5pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="mso-ansi-language: IN;">Legino, S.Kep
Ns Selaku Pembimbing Ruang IGD Rumah Sakit Umum Daerah Saras Husada Purworejo</span><span lang="EN-US"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt; text-align: justify; text-indent: 36.0pt;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span lang="EN-US">Penulis menyadari </span><span style="mso-ansi-language: IN;">Makalah</span><span lang="EN-US"> ini jauh dari kesempurnaan, oleh karena itu
penulis sangat mengharapkan kritikan dan saran yang membangun demi kesempurnaan
</span><span style="mso-ansi-language: IN;">Makalah ini</span><span lang="EN-US">.</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span lang="EN-US">Penulis berharap semoga makalah ini bermanfaat bagi kita
semua,<span style="mso-spacerun: yes;"> </span>khususnya profesi keperawatan.</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 36.0pt; text-align: justify; text-indent: 36.0pt;">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 150%; margin-left: 36.0pt; text-align: center; text-indent: 36.0pt;">
<span style="mso-ansi-language: IN;">Purworejo</span><span lang="EN-US">,<span style="mso-spacerun: yes;"> </span></span><span style="mso-ansi-language: IN;">April 2013</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; margin-left: 36.0pt; text-align: center; text-indent: 36.0pt;">
<span lang="EN-US">Penulis</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b><span style="mso-ansi-language: IN;">DAFTAR ISI</span></b></div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Cover</span></b><span style="mso-ansi-language: IN;">..................................................................................................................<span style="mso-tab-count: 1;"> </span>1</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Kata Pengantar</span></b><span style="mso-ansi-language: IN;">..................................................................................................<span style="mso-tab-count: 1;"> </span>2</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Daftar Isi</span></b><span style="mso-ansi-language: IN;">
............................................................................................................<span style="mso-tab-count: 1;"> </span>3</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">BAB I<span style="mso-tab-count: 1;"> </span></span><span lang="EN-US">PENDAHULUAN</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 72.0pt; mso-list: l22 level2 lfo123; text-indent: -18.0pt;">
<span style="mso-ansi-language: IN;"><span style="mso-list: Ignore;">A.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Latar Belakang………………………………………………</span><span style="mso-ansi-language: IN;">...</span><span lang="EN-US"><span style="mso-tab-count: 1;"> </span></span><span style="mso-ansi-language: IN;">5</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 72.0pt; mso-list: l22 level2 lfo123; text-indent: -18.0pt;">
<span style="mso-ansi-language: IN;"><span style="mso-list: Ignore;">B.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Tujuan
Penulisan………………………………………………<span style="mso-tab-count: 1;"> </span></span><span style="mso-ansi-language: IN;">5</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 72.0pt; mso-list: l22 level2 lfo123; text-indent: -18.0pt;">
<span style="mso-ansi-language: IN;"><span style="mso-list: Ignore;">C.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Metode
Penulisan……………………………………………..</span><span style="mso-ansi-language: IN;">.</span><span lang="EN-US"><span style="mso-tab-count: 1;"> </span></span><span style="mso-ansi-language: IN;">6</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 72.0pt; mso-list: l22 level2 lfo123; text-indent: -18.0pt;">
<span style="mso-ansi-language: IN;"><span style="mso-list: Ignore;">D.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Sistematika
Penulisan…………………………………………</span><span style="mso-ansi-language: IN;">.</span><span lang="EN-US"><span style="mso-tab-count: 1;"> </span></span><span style="mso-ansi-language: IN;">6</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 72.0pt;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">BAB II<span style="mso-spacerun: yes;"> </span></span><span lang="EN-US">TINJAUAN TEORITIS</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 63.8pt; mso-list: l32 level2 lfo124; text-indent: -14.15pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">A.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Konsep Dasar Medis</span></div>
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<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pengertian
…………………………………………………..<span style="mso-tab-count: 1;"> </span></span><span style="mso-ansi-language: IN;">7</span><span lang="EN-US"></span></div>
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<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Etiologi ……………………………………………………..<span style="mso-tab-count: 1;"> </span></span><span style="mso-ansi-language: IN;">7</span><span lang="EN-US"></span></div>
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<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Klasifikasi
…………………………………………………..<span style="mso-tab-count: 1;"> </span></span><span style="mso-ansi-language: IN;">10</span><span lang="EN-US"></span></div>
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<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Patofisiologi
………………………………………………..<span style="mso-tab-count: 1;"> </span></span><span style="mso-ansi-language: IN;">11</span><span lang="EN-US"></span></div>
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<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="mso-ansi-language: IN;">Pathway..................................................................................<span style="mso-tab-count: 1;"> </span>13</span><span lang="EN-US"></span></div>
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<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Manifestasi Klinis
………………………………………….<span style="mso-tab-count: 1;"> </span></span><span style="mso-ansi-language: IN;">15</span><span lang="EN-US"></span></div>
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<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">7.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Komplikasi …………………………………………………<span style="mso-tab-count: 1;"> </span></span><span style="mso-ansi-language: IN;">16</span><span lang="EN-US"></span></div>
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<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">8.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pemeriksaan Penunjang
……………………………………<span style="mso-tab-count: 1;"> </span>1</span><span style="mso-ansi-language: IN;">6</span><span lang="EN-US"></span></div>
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<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">9.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Penatalaksanaan
……………………………………………<span style="mso-tab-count: 1;"> </span>1</span><span style="mso-ansi-language: IN;">7</span><span lang="EN-US"></span></div>
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<span lang="EN-US"><span style="mso-list: Ignore;">B.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Konsep Dasar Keperawatan</span></div>
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<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pengkajian …………………………………………………<span style="mso-tab-count: 1;"> </span>1</span><span style="mso-ansi-language: IN;">7</span><span lang="EN-US"></span></div>
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<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Diagnosa Keperawatan
…………………………………….<span style="mso-tab-count: 1;"> </span></span><span style="mso-ansi-language: IN;">20</span><span lang="EN-US"></span></div>
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<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Intervensi Keperawatan
……………………………………<span style="mso-tab-count: 1;"> </span></span><span style="mso-ansi-language: IN;">21</span><span lang="EN-US"></span></div>
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<br /></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">BAB III<span style="mso-spacerun: yes;">
</span>TINJAUAN KASUS</span></b></div>
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<span lang="EN-US"><span style="mso-list: Ignore;">A.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pengkajian …………………………………………………….<span style="mso-tab-count: 1;"> </span>2</span><span style="mso-ansi-language: IN;">8</span><span lang="EN-US"></span></div>
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<span lang="EN-US"><span style="mso-list: Ignore;">B.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Diagnosa Keperawatan
…………………….…………………<span style="mso-tab-count: 1;"> </span></span><span style="mso-ansi-language: IN;">41</span><span lang="EN-US"></span></div>
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<span lang="EN-US"><span style="mso-list: Ignore;">C.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Intervensi Keperawatan……………………..………………....<span style="mso-tab-count: 1;"> </span></span><span style="mso-ansi-language: IN;">42</span><span lang="EN-US"></span></div>
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<span lang="EN-US"><span style="mso-list: Ignore;">D.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Implementasi Keperawatan
………………………………......<span style="mso-tab-count: 1;"> </span></span><span style="mso-ansi-language: IN;">45</span><span lang="EN-US"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 67.5pt;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 67.5pt;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">BAB IV<span style="mso-spacerun: yes;">
</span>PEMBAHASAN</span></b></div>
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<span lang="EN-US"><span style="mso-list: Ignore;">A.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pembahasan</span><span style="mso-ansi-language: IN;">
..........................................................................</span><span lang="EN-US">..</span><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 1;"> </span></span><span lang="EN-US">6</span><span style="mso-ansi-language: IN;">9</span><span lang="EN-US"></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">BAB V<span style="mso-spacerun: yes;"> </span>PENUTUP</span></b></div>
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<span lang="EN-US"><span style="mso-list: Ignore;">A.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Kesimpulan………………………………………………….<span style="mso-tab-count: 1;"> </span>.<span style="mso-tab-count: 1;"> </span></span><span style="mso-ansi-language: IN;">72</span><span lang="EN-US"></span></div>
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<span lang="EN-US"><span style="mso-list: Ignore;">B.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Saran …………………………………………………………<span style="mso-tab-count: 1;"> </span></span><span style="mso-ansi-language: IN;">72</span><span lang="EN-US"></span></div>
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<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Daftar Pustaka</span></b><span style="mso-ansi-language: IN;">
................................................................................................<span style="mso-tab-count: 1;"> </span>74</span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Lampiran</span></b></div>
<div class="MsoNormal">
<br /></div>
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<br /></div>
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; letter-spacing: -.95pt; mso-ansi-language: EN-US; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;"><br clear="all" style="mso-special-character: line-break; page-break-before: always;" />
</span>
<div class="MsoNormal">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">BAB I<span style="mso-tab-count: 1;"> </span><br />
PENDAHULUAN</span></b></div>
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<br /></div>
<div class="MsoNormal" style="line-height: 150%; tab-stops: 18.0pt; text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">A. Latar Belakang</span></b></div>
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<span lang="EN-US">Stroke adalah penyebab kematian yang
utama.Pola penyebab kematian di rumah sakit yang utama dari data Departemen
Kesehatan Republik Indonesia yang menyebutkan bahwa stroke menempati urutan
pertama sebagai penyebab kematian di RS.Stroke merupakan penyebab kematian
nomor tiga setelah penyakit jantung dan kanker secara global.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; text-align: justify; text-indent: 36.0pt;">
<span lang="EN-US">Stroke merupakan satu masalah
kesehatan yang besar dalam kehidupan modern saat ini. Di Indonesia,
diperkirakan setiap tahun terjadi 500.000 penduduk terkena serangan stroke, sekitar
2,5 % atau 125.000 orang meninggal, dan sisanya cacat ringan maupun berat.
Jumlah penderita stroke cenderung terus meningkat setiap tahun, bukan hanya
menyerang penduduk usia tua, tetapi juga dialami oleh mereka yang berusia muda
dan produktif. Stroke dapat menyerang setiap usia, namun yang sering terjadi
pada usia di atas 40 tahun. Angka kejadian stroke meningkat dengan bertambahnya
usia, makin tinggi usia seseorang, makin tinggi kemungkinan terkena serangan
stroke (Yayasan Stroke Indonesia, 2006).</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; text-align: justify; text-indent: 36.0pt;">
<span lang="EN-US">Angka kejadian stroke memang
meningkat seiring bertambahnya usia. Setiap penambahan usia 10 tahun sejak usia
35 tahun, risiko stroke meningkat dua kali lipat. Selain itu,sekitar 5% orang
Indonesia yang berusia diatas 65 tahun pernah mengalami setidaknya satu kali
stroke. Untuk usia lebih dari 5 tahun, penyebab kematian yang terbanyak adalah
stroke, baik di perkotaan maupun di perdesaan (Riskesdas, 2007). Prevalensi
nasional stroke adalah 0,8% (berdasarkan diagnosis tenaga kesehatan dan
gejala). Berdasarkan kasus diatas maka penulis tertarik untuk membahas tentang
perawatan klien dengan stroke sebagai bahan makalah kelompok dengan judul
“Asuhan Keperawatan Pada Ny.</span><span style="mso-ansi-language: IN;">H</span><span lang="EN-US"> Dengan Stroke Hemoragic </span><span lang="SV" style="mso-ansi-language: SV;">di RuangICURSUD Saras Husada Purworejo.</span><span lang="EN-US"></span></div>
<div class="MsoNormal" style="line-height: 150%; tab-stops: 18.0pt; text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span lang="FI" style="mso-ansi-language: FI;">B. Tujuan</span></b></div>
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<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Tujuan umum</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Mahasiswa mampu menerapkan asuhan keperawatan pada klien dengan <span style="color: black;">stroke hemoragic.</span></span><span style="color: black; mso-ansi-language: IN;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l51 level2 lfo8; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Tujuan Khusus</span></div>
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<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Mahasiswa mampu melakukan
pengkajian data pada klien dengan <span style="color: black;">stroke hemoragic</span></span></div>
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<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Mahasiswa mampu menganalisa
data hasil pengkajian pada klien dengan <span style="color: black;">stroke hemoragic</span></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 54.0pt; mso-add-space: auto; mso-list: l58 level3 lfo9; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Mahasiswa mampu melakukan
rencana tindakan pada klien dengan <span style="color: black;">stroke hemoragic</span></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 54.0pt; mso-add-space: auto; mso-list: l58 level3 lfo9; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Mahasiswa mampu melakukan
tindakan keperawata pada klien dengan <span style="color: black;">stroke
hemoragic</span></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 54.0pt; mso-add-space: auto; mso-list: l58 level3 lfo9; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">e.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Mahasiswa mampu mengevaluasi
hasil tindakan yang telah dilakukan pada klien dengan <span style="color: black;">stroke
hemoragic</span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 36.0pt;">
<br /></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">C.<span style="mso-spacerun: yes;"> </span>Metode Penulisan</span></b></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; text-indent: 18.0pt;">
<span lang="EN-US">Dalam penulisan
makalah ini, penulis menggunakan metode deskriptif yaitu dengan penjabaran
masalah-masalah yang didapatkan dan menggunakan studi kepustakaan dari
literatur yang ada, baik di buku, jurnal maupun di internet.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; text-indent: 18.0pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">D. <span style="mso-spacerun: yes;"> </span>Sistematika Penulisan</span></b></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto;">
<span lang="EN-US">Makalah ini terdiri dari empat bab yang
disusun dengan sistematika penulisan sebagai berikut:</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 72.0pt; mso-add-space: auto; text-indent: -54.0pt;">
<span lang="EN-US">BAB I<span style="mso-tab-count: 1;"> </span>: Pendahuluan, terdiri dari latar
belakang, tujuan<span style="mso-spacerun: yes;"> </span>penulisan,<span style="mso-spacerun: yes;"> </span>metode<span style="mso-spacerun: yes;">
</span></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 72.0pt; mso-add-space: auto;">
<span lang="EN-US">penulisan, dan sistematika penulisan.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 72.0pt; mso-add-space: auto; text-indent: -54.0pt;">
<span lang="EN-US">BAB II<span style="mso-tab-count: 1;"> </span>: Tinjauan teoritis terdiri dari :
pengertian, anatomi fisiologis, klasifikasi,<span style="mso-spacerun: yes;">
</span></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 72.0pt; mso-add-space: auto;">
<span lang="EN-US">etiologi, patofisiologi dan pathway,
manifestasi klinis, penatalaksanaan, </span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 72.0pt; mso-add-space: auto;">
<span lang="EN-US">komplikasi dan pemeriksaan penunjang.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 72.0pt; mso-add-space: auto; text-indent: -54.0pt;">
<span lang="EN-US">BAB III<span style="mso-tab-count: 1;"> </span>: Laporan kasus terdiri dari pengkajian,
diagnosa, intervensi, implementasi </span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 72.0pt; mso-add-space: auto;">
<span lang="EN-US">dan evaluasi.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto;">
<span lang="EN-US">BAB IV<span style="mso-tab-count: 1;"> </span>:
Pembahasan yang terdiri dari perbandingan jurnal dengan teori dan praktek </span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 54.0pt; mso-add-space: auto; text-indent: 18.0pt;">
<span lang="EN-US">lapangan yang
ditemukan.</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto;">
<span lang="EN-US">BAB V<span style="mso-tab-count: 1;"> </span>:
Penutup terdiri dari<span style="mso-spacerun: yes;"> </span>kesimpulan dan
saran.</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 0cm; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 0cm; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 0cm; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 0cm; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 0cm; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV;">BAB II</span></b></div>
<div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 0cm; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV;">TINJAUAN TEORITIS</span></b></div>
<div class="MsoNormal" style="line-height: 150%; tab-stops: 0cm;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; mso-list: l83 level1 lfo10; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">A.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV;">Konsep Dasar Medis</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 42.55pt; mso-list: l30 level1 lfo11; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV;">Pengertian </span></b></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 45.0pt; mso-add-space: auto; text-align: justify; text-indent: 33.0pt;">
<span lang="EN-US" style="mso-fareast-language: IN;">Cedera serebrovaskular atau stroke meliputi
awitan tiba-tiba defisit neurologis karena insufisiensi suplai darah ke suatu
bagian dari otak. Insufisiensi suplai darah disebabkan oleh trombus, biasanya
sekunder terhadap arterisklerosis, terhadap embolisme berasal dari tempat lain
dalam tubuh, atau terhadap perdarahan akibat ruptur arteri (aneurisma)</span><span style="mso-ansi-language: IN; mso-fareast-language: IN;">.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 45.0pt; mso-add-space: auto; text-align: justify; text-indent: 33.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="mso-fareast-language: IN;">Menurut WHO. (</span></b><b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN; mso-fareast-language: IN;">2007</span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="mso-fareast-language: IN;">) </span></b><span lang="EN-US" style="mso-fareast-language: IN;">Stroke adalah
disfungsi neurologi akut yang disebabkan oleh gangguan aliran darah yang timbul
secara mendadak dengan tanda dan gejala sesuai dengan daerah fokal pada otak
yang terganggu.</span><span style="mso-ansi-language: IN; mso-fareast-language: IN;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 45.0pt; mso-add-space: auto; text-align: justify; text-indent: 33.0pt;">
<span lang="SV" style="mso-ansi-language: SV;">Stroke terdiri dari 2 jenis yaitu : Stroke adalah
sindrom yang awal timbulnya mendadak, progresif cepat, berupa deficit
neurologis fokal atau global yang langsung 24 jam atau lebih atau langsung
menimbulkan kematian, dan semata-mata disebabkan oleh gangguan peredaran otak
non traumatic (Mansjoer 2007).</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 45.0pt; mso-add-space: auto; text-align: justify; text-indent: 33.0pt;">
<span lang="SV" style="mso-ansi-language: SV;">Stroke adalah suatu penyakit gangguan fungsi anatomi
otak yang terjadi secara tiba-tiba dan cepat, disebabkan karena gangguan
perdarahan otak. Stroke atau Cerebro Vasculer Accident (CVA) adalah kehilangan
fungsi otak yang diakibatkan oleh berhentinya suplai darah ke bagian otak (
Brunner dan Suddarth, 2008 ).</span><span lang="EN-US" style="mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; tab-stops: 36.0pt 54.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; mso-list: l30 level1 lfo11; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV;">Etiologi</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; text-align: justify;">
<span lang="SV" style="mso-ansi-language: SV;">Beberapa keadaan dibawah ini
dapat menyebabkan stroke antara lain :</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 49.65pt; mso-add-space: auto; mso-list: l51 level3 lfo8; text-align: justify; text-indent: -14.4pt;">
<span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Thrombosis
Cerebral.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 49.65pt; mso-add-space: auto; text-align: justify;">
<span lang="SV" style="mso-ansi-language: SV;">Thrombosis ini terjadi pada pembuluh darah yang mengalami oklusi sehingga
menyebabkan iskemi jaringan otak yang dapa menimbulkan oedema dan kongesti di
sekitarnya.Thrombosis biasanya terjadi pada orang tua yang sedang tidur atau
bangun tidur. Hal ini dapat terjadi karena penurunan aktivitas simpatis dan
penurunan tekanan darah yang dapat menyebabkan iskemi serebral.Tanda dan gejala
neurologis seringkali memburuk pada 48 jam sete;ah thrombosis.</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 49.65pt; mso-add-space: auto; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 49.65pt; mso-add-space: auto; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; text-align: justify;">
<span lang="SV" style="mso-ansi-language: SV;">Beberapa keadaandibawah ini
dapat menyebabkan thrombosis otak :</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 2.0cm; mso-add-space: auto; mso-list: l120 level1 lfo110; text-align: justify; text-indent: -18.0pt;">
<i style="mso-bidi-font-style: normal;"><span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1)<span style="font: 7.0pt "Times New Roman";"> </span></span></span></i><i style="mso-bidi-font-style: normal;"><span lang="SV" style="mso-ansi-language: SV;">Atherosklerosis</span></i></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 2.0cm; mso-add-space: auto; text-align: justify;">
<i style="mso-bidi-font-style: normal;"><span lang="SV" style="mso-ansi-language: SV;">Atherosklerosis</span></i><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-spacerun: yes;"> </span>adalah
mengerasnya pembuluh darah serta berkurangnya kelenturan atau elastisitas
dinding pembuluh darah. Manifestasi klinis atherosklerosis bermacam-macam.
Kerusakan dapat terjadi melalui mekanisme berikut :</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 89.45pt; mso-add-space: auto; mso-list: l82 level1 lfo111; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">a)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Lumen
arteri menyempit dan mengakibatkan berkurangnya aliran darah.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 89.45pt; mso-add-space: auto; mso-list: l82 level1 lfo111; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">b)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Oklusi
mendadak pembuluh darah<span style="mso-spacerun: yes;"> </span>karena terjadi
thrombosis.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 89.45pt; mso-add-space: auto; mso-list: l82 level1 lfo111; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">c)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Merupakan
tempat terbentuknya thrombus, kemudian melepaskan kepingan thrombus (embolus)</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 89.45pt; mso-add-space: auto; mso-list: l82 level1 lfo111; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">d)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Dinding
arteri menjadi lemah dan terjadi aneurisma kemudian robek dan terjadi perdarahan.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 2.0cm; mso-add-space: auto; mso-list: l120 level1 lfo110; text-align: justify; text-indent: -14.15pt;">
<span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Hypercoagulasi
pada polysitemia</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 2.0cm; mso-add-space: auto; text-align: justify;">
<span lang="SV" style="mso-ansi-language: SV;">Darah bertambah kental , peningkatan viskositas /hematokrit meningkat dapat
melambatkan aliran darah serebral.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 2.0cm; mso-add-space: auto; mso-list: l120 level1 lfo110; text-align: justify; text-indent: -14.15pt;">
<span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Arteritis(
radang pada arteri )</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 53.5pt; mso-add-space: auto; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 49.65pt; mso-add-space: auto; mso-list: l51 level3 lfo8; text-align: justify; text-indent: -14.15pt;">
<i style="mso-bidi-font-style: normal;"><span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></i><i style="mso-bidi-font-style: normal;"><span lang="SV" style="mso-ansi-language: SV;">Emboli</span></i></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 49.65pt; mso-add-space: auto; text-align: justify;">
<span lang="SV" style="mso-ansi-language: SV;">Emboli serebral merupakan penyumbatan pembuluh darah otak oleh bekuan
darah, lemak dan udara. Pada umumnya emboli berasal dari thrombus di jantung
yang terlepas dan menyumbat sistem arteri serebral. Emboli tersebut berlangsung
cepat dan gejala timbul kurang dari 10-30 detik. Beberapa keadaan dibawah ini
dapat menimbulkan emboli :</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 92.15pt; mso-add-space: auto; mso-list: l13 level1 lfo112; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Katup-katup
jantung yang rusak akibat <i style="mso-bidi-font-style: normal;">Rheumatik Heart
Desease</i>.(RHD)</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 92.15pt; mso-add-space: auto; mso-list: l13 level1 lfo112; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Myokard
infark</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 92.15pt; mso-add-space: auto; mso-list: l13 level1 lfo112; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Fibrilasi,.
Keadaan aritmia menyebabkan berbagai bentuk pengosongan ventrikel sehingga
darah terbentuk gumpalan kecil dan sewaktu-waktu kosong sama sekali dengan
mengeluarkan embolus-embolus kecil.</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 92.15pt; mso-add-space: auto; mso-list: l13 level1 lfo112; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Endokarditis
oleh bakteri dan non bakteri, menyebabkan terbentuknya gumpalan-gumpalan pada
endocardium.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 54.0pt; tab-stops: 54.0pt; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 49.65pt; mso-add-space: auto; mso-list: l51 level3 lfo8; text-align: justify; text-indent: -14.15pt;">
<i style="mso-bidi-font-style: normal;"><span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></i><i style="mso-bidi-font-style: normal;"><span lang="SV" style="mso-ansi-language: SV;">Haemorhagi</span></i></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 49.65pt; mso-add-space: auto; text-align: justify;">
<span lang="SV" style="mso-ansi-language: SV;">Perdarahan intrakranial atau intraserebral termasuk perdarahan dalam ruang
subarachnoid atau kedalam jaringan otak sendiri. Perdarahan ini dapat terjadi
karena atherosklerosis dan hypertensi. Akibat pecahnya pembuluh darah otak
menyebabkan perembesan darah kedalam parenkim otak yang dapat mengakibatkan
penekanan, pergeseran dan pemisahan jaringan otak yang berdekatan ,sehingga
otak akan membengkak, jaringan otak tertekan, sehingga terjadi infark otak,
oedema, dan mungkin herniasi otak.</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 49.65pt; mso-add-space: auto; text-align: justify;">
<span lang="SV" style="mso-ansi-language: SV;">Penyebab perdarahan otak yang paling lazim terjadi :</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 70.9pt; mso-add-space: auto; mso-list: l60 level1 lfo113; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Aneurisma
Berry,biasanya defek kongenital.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 70.9pt; mso-add-space: auto; mso-list: l60 level1 lfo113; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Aneurisma
fusiformis dari atherosklerosis.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 70.9pt; mso-add-space: auto; mso-list: l60 level1 lfo113; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Aneurisma
myocotik dari vaskulitis nekrose dan emboli septis.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 70.9pt; mso-add-space: auto; mso-list: l60 level1 lfo113; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Malformasi
arteriovenous, terjadi hubungan persambungan pembuluh darah arteri, sehingga
darah arteri langsung masuk vena.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 70.9pt; mso-add-space: auto; mso-list: l60 level1 lfo113; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">5)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Ruptur
arteriol serebral, akibat hipertensi yang menimbulkan penebalan dan degenerasi
pembuluh darah.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 70.9pt; mso-add-space: auto; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 49.65pt; mso-add-space: auto; mso-list: l51 level3 lfo8; text-align: justify; text-indent: -14.15pt;">
<span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Hypoksia
Umum</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 70.9pt; mso-add-space: auto; mso-list: l80 level1 lfo114; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Hipertensi
yang parah.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 70.9pt; mso-add-space: auto; mso-list: l80 level1 lfo114; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Cardiac
Pulmonary Arrest</span></div>
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<span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Cardiac
output turun akibat aritmia</span></div>
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<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 49.65pt; mso-add-space: auto; mso-list: l51 level3 lfo8; text-align: justify; text-indent: -14.15pt;">
<span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">e.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Hipoksia
setempat</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 70.9pt; mso-add-space: auto; mso-list: l116 level1 lfo115; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Spasme
arteri serebral , yang disertai perdarahan subarachnoid.</span></div>
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<span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Vasokontriksi
arteri otak disertai sakit kepala migrain.</span></div>
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<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 49.65pt; text-align: justify;">
<span lang="SV" style="mso-ansi-language: SV;">Faktor Resiko Tambahan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 72.0pt; mso-list: l71 level1 lfo2; tab-stops: 54.0pt list 72.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Kadar lemak darah yang tinggi termasuk
Kolesterol dan Trigliserida. Meningginya kadar kolesterol merupakan factor
penting untuk terjadinya arteriosklerosis atau menebalnya dinding pembuluh
darah yang diikuti penurunan elastisitas pembuluh darah.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 72.0pt; mso-list: l71 level1 lfo2; tab-stops: 54.0pt list 72.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Kegemukan atau obesitas</span></div>
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<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Merokok<br />
Merokok dapat meningkatkan konsentrasi fibrinogen yang akan mempermudah
terjadinya penebalan dinding pembuluh darah dan peningkatan kekentalan darah.</span></div>
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<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Riwayat keluarga dengan stroke</span></div>
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<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">e.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Lanjut usia</span></div>
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<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">f.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Penyakit darah tertentu seperti
polisitemia dan leukemia. Polisitemia dapat menghambat kelancaran aliran darah
ke otak. </span><span lang="SV" style="mso-ansi-language: SV;">Sementara leukemia/
kanker darah dapat menyebabkan terjadinya pendarahan otak.</span></div>
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<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">g.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Kadar asam urat darah tinggi</span></div>
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<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">h.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Penyakit paru- paru menahun.</span></div>
<div class="MsoNormal" style="line-height: 150%; tab-stops: 54.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; mso-list: l30 level1 lfo11; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV;">Klasifikasi</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 36.0pt; text-align: justify; text-indent: 36.0pt;">
<span lang="SV" style="mso-ansi-language: SV;">Menurut
Lumbantobing (2007) kelainan yang terjadi akibat gangguan peredaran darah.
Stroke dapat dibagi menjadi 2 golongan, yaitu:</span></div>
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<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><i style="mso-bidi-font-style: normal;"><span lang="EN-US">Infark Ischemik (Stroke non
Hemoragi</span></i><span lang="EN-US">). </span><span lang="SV" style="mso-ansi-language: SV;">Hal ini terjadi karena adanya penyumbatan pembuluh darah otak. Infark
iskemic terbagi menjadi dua yaitu : stroke trombotik, yang disebabkan oleh
thrombus dan stroke embolik, yang disebabkan oleh embolus.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 54.0pt; tab-stops: 36.0pt; text-align: justify;">
<span lang="SV" style="mso-ansi-language: SV;">Membagi
stroke non haemoragi berdasarkan bentuk klinisnya antara lain :</span></div>
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<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">1)<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Serangan Iskemia sepintas atau <i style="mso-bidi-font-style: normal;">transient ischemic Attack</i> (TIA).<br />
Pada bentuk ini gejala neurologik yang timbul akibat gangguan peredaran darah
di otak akan menghilang dalam waktu 24 jam.</span></div>
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<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">2)<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Defisit Neurologik Iskemia Sepintas/ <i style="mso-bidi-font-style: normal;">Reversible Ischemic Neurologik Defisit</i>
(RIND). Gejala neurologik timbul ± 24 jam, tidak lebih dari seminggu.</span></div>
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<span lang="EN-US"><span style="mso-list: Ignore;">3)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Stroke Progresif (<i style="mso-bidi-font-style: normal;">Progresive Stroke/ Stroke in evolution</i>).<br />
Gejala makin berkembang ke otak lebih berat.</span></div>
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<span lang="EN-US"><span style="mso-list: Ignore;">4)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Completed Stroke<span style="mso-tab-count: 1;"> </span><br />
Kelainan saraf yang sifatnya sudah menetap, tidak berkembang lagi.</span></div>
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<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.0cm; mso-list: l75 level3 lfo6; tab-stops: 36.0pt list 54.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Perdarahan (Stroke Hemoragi). </span></div>
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<span lang="EN-US">Pembuluh darah otak yang pecah
menyebabkan darah mengalir ke substansi atau ruangan subarachnoid yang
menimbulkan perubahan komponen intracranial yang seharusnya konstan. Adanya
perubahan komponen intracranial yang tidak dapat dikompensasi tubuh akan
menimbulkan peningkatan TIK yang bila berlanjut akan menyebabkan herniasi otak
sehingga timbul kematian. Di samping itu, darah yang mengalir ke substansi otak
atau ruang subarachnoid dapat menyebabkan edema, spasme pembuluh darah otak dan
penekanan pada daerah tersebut menimbulkan aliran darah berkurang atau tidak
ada sehingga terjadi nekrosis jaringan otak. (Arif mutakin,2008)</span></div>
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<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; mso-list: l30 level1 lfo11; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV;">Patofisiologi</span></b></div>
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<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Stroke Hemoragic<span style="mso-tab-count: 1;"> </span><br />
Perdarahan serebri termasuk urutan ketiga dari semua penyebab utama kasus
gangguan pembuluh darah otak. Perdarahan serebral dapat terjadi di luar
duramater (hemoragi ekstradural atau epidural), dibawah duramater, (hemoragi
subdural), diruang subarachnoid (hemoragi subarachnoid) atau di dalam substansi
otak (hemoragi intraserebral). Hemoragi ekstradural (epidural) adalah
kedaruratan bedah neuro yang memerlukan perawatan segera. Ini biasanya
mengikuti fraktur tengkorak dengan robekan arteri dengan arteri meningea lain.
Hemoragi subdural (termasuk hemoragi subdural akut) pada dasarnya sama dengan
hemoragi epidural, kecuali bahwa hematoma subdural biasanya jembatan vena
robek. Karenanya, periode pembentukan hematoma lebih lama ( intervensi jelas
lebih lama) dan menyebabkan tekanan pada otak. Beberapa pasien mungkin
mengalami hemoragi subdural kronik tanpa menunjukkan tanda dan gejala. Hemoragi
subarachnoid dapat terjadi sebagai akibat trauma atau hipertensi, tetapi
penyebab paling sering adalah kebocoran aneurisma pada area sirkulus wilisi dan
malformasi arteri-vena kongenital pada otak. Arteri di dalam otak dapat menjadi
tempat aneurisma. Hemoragi intraserebral paling umum pada pasien dengan
hipertensi dan aterosklerosis serebral, karena perubahan degeneratif karena
penyakit ini biasanya menyebabkan ruptur pembuluh darah. pada orang yang lebih
muda dari 40 tahun, hemoragi intraserebral biasanya disebabkan oleh malformasi
arteri-vena, hemangioblastoma dan trauma, juga disebabkan oleh tipe patologi
arteri tertentu, adanya tumor otak dan penggunaan medikasi (antikoagulan oral,
amfetamin dan berbagai obat aditif). Perdarahan biasanya arterial dan terjadi
terutama sekitar basal ganglia. Biasanya awitan tiba-tiba dengan sakit kepala
berat. Bila hemoragi membesar, makin jelas defisit neurologik yang terjadi
dalam bentuk penurunan kesadaran dan abnormalitas pada tanda vital. Pasien
dengan perdarahan luas dan hemoragi mengalami penurunan kesadaran dan
abnormalitas pada tanda vital.</span></div>
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<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Stroke Non Hemoragic</span></div>
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<span lang="SV" style="mso-ansi-language: SV;">Terbagi
atas 2 yaitu :<span style="mso-tab-count: 1;"> </span></span></div>
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<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">1)<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Pada stroke trombotik, oklusi disebabkan
karena adanya penyumbatan lumen pembuluh darah otak karena thrombus yang makin
lama makin menebal, sehingga aliran darah menjadi tidak lancar. Penurunan
aliran arah ini menyebabkan iskemik yang akan berlanjut menjadi infark. Dalam
waktu 72 jam daerah tersebut akan mengalami edema dan lama kelamaan akan
terjadi nekrosis. Lokasi yang tersering pada stroke trombosis adalah di
percabangan arteri carotis besar dan arteri vertebra yang berhubungan dengan
arteri basiler. Onset stroke trombotik biasanya berjalan lambat.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 72.0pt; tab-stops: 54.0pt; text-align: justify;">
<span lang="SV" style="mso-ansi-language: SV;">Sedangkan
stroke emboli terjadi karena adanya emboli yang lepas dari bagian tubuh lain
sampai ke arteri carotis, emboli tersebut terjebak di pembuluh darah otak yang
lebih kecil dan biasanya pada daerah percabangan lumen yang menyempit, yaitu
arteri carotis di bagian tengah atau Middle Carotid Artery ( MCA ). Dengan
adanya sumbatan oleh emboli akan menyebabkan iskemik.</span></div>
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<br /></div>
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<br /></div>
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<br /></div>
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<br /></div>
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<br /></div>
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<br /></div>
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<br /></div>
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<br /></div>
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<br /></div>
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<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
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<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
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<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
</div>
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN; mso-bidi-language: AR-SA; mso-fareast-font-family: SimSun; mso-fareast-language: ZH-CN;"><br clear="all" style="mso-break-type: section-break; page-break-before: always;" />
</span></b>
<div class="WordSection2">
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 45.0pt; mso-add-space: auto; mso-list: l30 level1 lfo11; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Pathway</span></b></div>
<div class="MsoNormal" style="tab-stops: 180.0pt 432.0pt;">
<span lang="EN-US"><span style="mso-tab-count: 1;"> </span></span></div>
<div class="MsoNormal" style="tab-stops: 180.0pt 432.0pt;">
<br /></div>
<div class="MsoNormal" style="tab-stops: 207.0pt 481.5pt;">
<span lang="EN-US"><span style="mso-tab-count: 1;"> </span>Hipertensi<span style="mso-spacerun: yes;"> </span><span style="mso-tab-count: 1;"> </span>DM</span></div>
<div class="MsoNormal" style="tab-stops: 180.0pt 481.5pt;">
<span lang="EN-US"> </span></div>
<br clear="ALL" style="mso-ignore: vglayout;" />
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US">Penimbunan lemak/ Kolesterol dalam darah</span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
<div class="MsoNormal" style="tab-stops: 139.5pt 324.0pt; text-align: justify;">
<span lang="EN-US">Penyempitan Pembuluh Darah<span style="mso-tab-count: 1;"> </span>Trombus</span></div>
<div class="MsoNormal" style="tab-stops: 139.5pt 324.0pt; text-align: justify;">
<span lang="EN-US"> </span></div>
<div class="MsoNormal" style="tab-stops: 139.5pt 324.0pt; text-align: justify;">
<br /></div>
<br clear="ALL" style="mso-ignore: vglayout;" />
<div class="MsoNormal" style="tab-stops: 139.5pt 324.0pt; text-align: justify;">
<span lang="EN-US">Tekanan kapiler naik</span></div>
<div class="MsoNormal" style="tab-stops: 139.5pt 324.0pt; text-align: justify;">
<span lang="EN-US"> </span></div>
<div class="MsoNormal" style="tab-stops: 139.5pt 324.0pt; text-align: justify;">
<br /></div>
<br clear="ALL" style="mso-ignore: vglayout;" />
<div class="MsoNormal" style="tab-stops: 139.5pt 324.0pt; text-align: justify;">
<span lang="EN-US">Volume interstisial meningkat</span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US">Pembuluh darah kaku dan pecah</span></div>
<div class="MsoNormal">
<span lang="EN-US"> </span></div>
<br clear="ALL" style="mso-ignore: vglayout;" />
<div class="MsoNormal">
<span lang="EN-US"><span style="mso-spacerun: yes;">
</span>EDEMA</span></div>
<div class="MsoNormal">
<span lang="EN-US"> </span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
<br clear="ALL" style="mso-ignore: vglayout;" />
<div class="MsoNormal" style="tab-stops: 288.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Kelebihan Volume cairan</span></b><span lang="EN-US"> <span style="mso-tab-count: 1;"> </span><b style="mso-bidi-font-weight: normal;">STROKE HAEMORHAGIC</b></span></div>
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-US; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;"><br clear="all" style="mso-special-character: line-break; page-break-before: always;" />
</span></b>
<div class="MsoNormal" style="line-height: 115%; margin-bottom: 10.0pt;">
<br /></div>
<div align="center" class="MsoNormal" style="tab-stops: 288.0pt; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">STROKE HAEMORHAGIC</span></b><span lang="EN-US"></span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US"> </span></b></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
<br clear="ALL" style="mso-ignore: vglayout;" />
<div align="center" class="MsoNormal" style="margin-left: 108.0pt; text-align: center; text-indent: 36.0pt;">
<span lang="EN-US"><span style="mso-spacerun: yes;"> </span>Pecahnya
pembuluh darah otak<span style="mso-tab-count: 4;"> </span>Perdarahan
Intrakranial</span></div>
<div align="center" class="MsoNormal" style="margin-left: 108.0pt; text-align: center; text-indent: 36.0pt;">
<span lang="EN-US"> </span></div>
<div align="center" class="MsoNormal" style="margin-left: 108.0pt; text-align: center; text-indent: 36.0pt;">
<br /></div>
<br clear="ALL" style="mso-ignore: vglayout;" />
<div class="MsoNormal" style="text-align: justify; text-indent: 36.0pt;">
<span lang="EN-US">Kerusakan neuromuskuler<span style="mso-tab-count: 2;"> </span><span style="mso-spacerun: yes;"> </span>CBF (
aliran darah ke otak )<span style="mso-tab-count: 1;"> </span>
Perembesan ke parenkim otak<span style="mso-spacerun: yes;"> </span>Penekanan
kortek cerebri</span></div>
<div class="MsoNormal" style="text-align: justify; text-indent: 36.0pt;">
<span lang="EN-US"> </span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
<br clear="ALL" style="mso-ignore: vglayout;" />
<div class="MsoNormal" style="text-indent: 36.0pt;">
<span lang="EN-US">Ggn transmisi input<span style="mso-tab-count: 1;"> </span>
Glukosa darah dalam<span style="mso-tab-count: 1;"> </span><span style="mso-spacerun: yes;"> </span>Suplay O2 ke otak<span style="mso-tab-count: 1;"> </span><span style="mso-spacerun: yes;"> </span>Pergeseran /
penekanan<span style="mso-tab-count: 1;"> </span><span style="mso-spacerun: yes;"> </span>gangguan N. Cranialis</span></div>
<div class="MsoNormal" style="text-indent: 36.0pt;">
<span lang="EN-US">UMN/ LMN<span style="mso-tab-count: 3;"> </span>otak<span style="mso-tab-count: 5;"> </span><span style="mso-spacerun: yes;"> </span>jaringan otak</span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US"> </span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
<br clear="ALL" style="mso-ignore: vglayout;" />
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US"><span style="mso-spacerun: yes;">
</span>Paralisis<span style="mso-tab-count: 2;"> </span>
Tingkat kesadaran<span style="mso-tab-count: 1;"> </span><span style="mso-spacerun: yes;"> </span>PH, PO2, PCO2<span style="mso-tab-count: 3;"> </span><span style="mso-spacerun: yes;"> </span>Gggn N V, VII,
IX,<span style="mso-spacerun: yes;"> </span>XII</span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US"> </span></div>
<br clear="ALL" style="mso-ignore: vglayout;" />
<div align="center" class="MsoNormal" style="margin-left: 288.0pt; text-align: center; text-indent: 36.0pt;">
<span lang="EN-US"><span style="mso-spacerun: yes;"> </span>PTIK<span style="mso-spacerun: yes;"> </span><b style="mso-bidi-font-weight: normal;">Ggn
perfusi jaringan</b></span><b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;"> cerebral</span></b><span style="mso-ansi-language: IN;"></span></div>
<div align="center" class="MsoNormal" style="margin-left: 288.0pt; text-align: center; text-indent: 36.0pt;">
<span lang="EN-US"> </span></div>
<br clear="ALL" style="mso-ignore: vglayout;" />
<div class="MsoNormal" style="text-align: justify;">
<span lang="EN-US">Kelemahan
pergerakan sendi<span style="mso-spacerun: yes;"> </span><b style="mso-bidi-font-weight: normal;"><span style="mso-spacerun: yes;"> </span>PSP</b><span style="mso-tab-count: 1;"> </span><span style="mso-spacerun: yes;"> </span>Hipoksia jaringan <span style="mso-tab-count: 1;"> </span><span style="mso-spacerun: yes;"> </span>CES<span style="mso-tab-count: 2;"> </span><span style="mso-spacerun: yes;"> </span>Fungsi mengunyah, menelan,<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal" style="margin-left: 216.0pt; text-align: justify;">
<span lang="EN-US">sensasi kecap</span></div>
<div class="MsoNormal" style="margin-left: 360.0pt; text-align: justify; text-indent: 36.0pt;">
<span lang="EN-US">dan pergerakan lidah</span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US"> </span></div>
<br clear="ALL" style="mso-ignore: vglayout;" />
<div class="MsoNormal" style="text-align: justify; text-indent: 36.0pt;">
<span lang="EN-US"><span style="mso-spacerun: yes;"> </span>Kontraktur<span style="mso-tab-count: 2;"> </span>sirkulasi ke otak<span style="mso-tab-count: 2;"> </span><span style="mso-spacerun: yes;"> </span>RR<span style="mso-tab-count: 2;"> </span><span style="mso-spacerun: yes;"> </span>Sekresi ADH<span style="mso-tab-count: 2;"> </span> Intake nutrisi per oral</span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US"> </span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
<br clear="ALL" style="mso-ignore: vglayout;" />
<div class="MsoNormal" style="text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Gangguan mobilisasi</span></b><span lang="EN-US"><span style="mso-tab-count: 3;"> </span><b style="mso-bidi-font-weight: normal;"><span style="mso-spacerun: yes;"> </span>Ggn pola
nafas</b><span style="mso-tab-count: 1;"> </span><span style="mso-spacerun: yes;"> </span>Perpindahan CES – CSS<span style="mso-tab-count: 1;"> </span><b style="mso-bidi-font-weight: normal;">Ggn keb nutrisi peroral</b></span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US"> </span></div>
<div align="center" class="MsoNormal" style="margin-left: 216.0pt; text-align: center; text-indent: 36.0pt;">
<br /></div>
<br clear="ALL" style="mso-ignore: vglayout;" />
<div class="MsoNormal" style="margin-left: 108.0pt; text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Ggn Komunikasi verbal<span style="mso-spacerun: yes;">
</span>Ggn eliminasi BAK</span></b></div>
</div>
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;"><br clear="all" style="mso-break-type: section-break; page-break-before: always;" />
</span>
<div class="WordSection3">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: IN;">Perbedaan antara infark dan perdarahan otak
sebagai berikut :</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; margin-left: 5.4pt; mso-padding-alt: 0cm 0cm 0cm 0cm; mso-yfti-tbllook: 1184; width: 561px;">
<tbody>
<tr style="height: 17.7pt; mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td style="border: solid windowtext 1.0pt; height: 17.7pt; mso-border-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 144.0pt;" valign="top" width="192">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-GB" style="mso-ansi-language: EN-GB;">Gejala(anamnesa)</span></b><b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;"></span></b></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; height: 17.7pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 126.0pt;" valign="top" width="168">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-GB" style="mso-ansi-language: EN-GB;">Infark</span></b><b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;"></span></b></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; height: 17.7pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 150.75pt;" valign="top" width="201">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-GB" style="mso-ansi-language: EN-GB;">Perdarahan</span></b><b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;"></span></b></div>
</td>
</tr>
<tr style="height: 66.3pt; mso-yfti-irow: 1;">
<td style="border-top: none; border: solid windowtext 1.0pt; height: 66.3pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 144.0pt;" valign="top" width="192">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: IN;">Permulaan</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: IN;">Waktu</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: IN;">Peringatan</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: IN;">Nyeri Kepala</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: IN;">Kejang</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: IN;">Kesadaran menurun</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 66.3pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 126.0pt;" valign="top" width="168">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">Sub akut</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">Bangun pagi</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">+ 50% TIA</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">-</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">-</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">Kadang sedikit</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 66.3pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 150.75pt;" valign="top" width="201">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">Sangat akut</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">Lagi aktifitas</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">-</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">+</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">++</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">+++</span></div>
</td>
</tr>
<tr style="height: 167.95pt; mso-yfti-irow: 2; mso-yfti-lastrow: yes;">
<td style="border-top: none; border: solid windowtext 1.0pt; height: 167.95pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 144.0pt;" valign="top" width="192">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: IN;">Gejala Objektif</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: IN;">Koma</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: IN;">Kaku kuduk</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: IN;">Kernig</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: IN;">pupil edema</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: IN;">Perdarahan Retina</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: IN;">Pemeriksaan Laboratorium</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: IN;">Darah pada LP</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: IN;">X foto Skedel</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: IN;">Angiografi</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: IN;">CT Scan.</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 167.95pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 126.0pt;" valign="top" width="168">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">Infark</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">+/-</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">-</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">-</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">-</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">-</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">-</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">+</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">Oklusi, stenosis</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">Densitas berkurang</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 167.95pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 150.75pt;" valign="top" width="201">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">Perdarahan</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">++</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">++</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">+</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">+</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">+</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">+</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">Kemungkinan pergeseran glandula pineal</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">Aneurisma</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">AVM. massa intra hemisfer/vasospasme.</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">Massa intrakranial densitas bertambah.</span></div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: IN;">Perbedaan perdarahan Intra Serebral (PIS) dan
Perdarahan Sub Arachnoid (PSA)</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: none; margin-left: 5.4pt; mso-border-alt: solid windowtext .5pt; mso-border-insideh: .5pt solid windowtext; mso-border-insidev: .5pt solid windowtext; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-table-layout-alt: fixed; mso-yfti-tbllook: 1184;">
<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td style="border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 144.0pt;" valign="top" width="192">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="EN-GB" style="mso-ansi-language: EN-GB;">Gejala</span><span style="mso-ansi-language: IN;"></span></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 162.0pt;" valign="top" width="216">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="EN-GB" style="mso-ansi-language: EN-GB;">PIS</span><span style="mso-ansi-language: IN;"></span></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 114.75pt;" valign="top" width="153">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="EN-GB" style="mso-ansi-language: EN-GB;">PSA</span><span style="mso-ansi-language: IN;"></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 1; mso-yfti-lastrow: yes;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 144.0pt;" valign="top" width="192">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: IN;">Timbulnya</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: IN;">Nyeri Kepala</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: IN;">Kesadaran</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: IN;">Kejang</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: IN;">Tanda rangsangan Meningeal.</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: IN;">Hemiparese</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: IN;">Gangguan saraf otak</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 162.0pt;" valign="top" width="216">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">Dalam 1 jam</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">Hebat</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">Menurun</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">Umum</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">+/-</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">++</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">+</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 114.75pt;" valign="top" width="153">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">1-2 menit</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">Sangat hebat</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">Menurun sementara</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">Sering fokal</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">+++</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">+/-</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">+++</span></div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: IN;">Jika dilihat bagian hemisfer yang terkena tanda
dan gejala dapat berupa:</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l119 level3 lfo1; text-align: justify; text-indent: -18.0pt;">
<span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="mso-ansi-language: IN;">Stroke
hemisfer Kanan</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 42.55pt; mso-add-space: auto; mso-list: l119 level4 lfo1; text-align: justify; text-indent: -18.0pt;">
<span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="mso-ansi-language: IN;">Hemiparese
sebelah kiri tubuh.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 42.55pt; mso-add-space: auto; mso-list: l119 level1 lfo1; tab-stops: list 144.0pt; text-align: justify; text-indent: -18.0pt;">
<span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="mso-ansi-language: IN;">Penilaian buruk</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 42.55pt; mso-add-space: auto; mso-list: l119 level1 lfo1; tab-stops: list 144.0pt; text-align: justify; text-indent: -18.0pt;">
<span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="mso-ansi-language: IN;">Mempunyai kerentanan terhadap sisi kolateral
sehingga kemungkinan terjatuh ke sisi yang berlawanan tersebut.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level1 lfo116; text-align: justify; text-indent: -18.0pt;">
<span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="mso-ansi-language: IN;">Stroke yang Hemifer
kiri</span></div>
<table border="0" cellpadding="0" cellspacing="0" class="MsoTableGrid" style="border-collapse: collapse; border: none; margin-left: 21.3pt; mso-border-insideh: none; mso-border-insidev: none; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-yfti-tbllook: 1184;">
<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 253.45pt;" valign="top" width="338">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 1.0cm; mso-add-space: auto; mso-list: l119 level4 lfo1; text-align: justify; text-indent: -18.0pt;">
<span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="mso-ansi-language: IN;">Mengalami
hemiparese kanan<span style="mso-spacerun: yes;"> </span></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 134.65pt;" valign="top" width="180">
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 30.05pt; mso-add-space: auto; mso-list: l20 level1 lfo118; text-align: justify; text-indent: -18.0pt;">
<span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="mso-ansi-language: IN;">Disfagia
global</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 1;">
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 253.45pt;" valign="top" width="338">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 1.0cm; mso-add-space: auto; mso-list: l62 level1 lfo117; text-align: justify; text-indent: -18.0pt;">
<span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="mso-ansi-language: IN;">Perilaku
lambat dan sangat hati-hati</span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 134.65pt;" valign="top" width="180">
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 30.05pt; mso-add-space: auto; mso-list: l20 level1 lfo118; text-align: justify; text-indent: -18.0pt;">
<span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">e.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="mso-ansi-language: IN;">Afasia</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 2; mso-yfti-lastrow: yes;">
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 253.45pt;" valign="top" width="338">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 1.0cm; mso-add-space: auto; mso-list: l62 level1 lfo117; text-align: justify; text-indent: -18.0pt;">
<span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="mso-ansi-language: IN;">Kelainan
bidang pandang sebelah kanan.</span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 134.65pt;" valign="top" width="180">
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 29.85pt; mso-add-space: auto; mso-list: l20 level1 lfo118; text-align: justify; text-indent: -18.0pt;">
<span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">f.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="mso-ansi-language: IN;">Mudah
frustasi</span></div>
</td>
</tr>
</tbody></table>
<div class="MsoListParagraph" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; mso-list: l30 level1 lfo11; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV;">Manifestasi Klinis</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 36.0pt; text-align: justify; text-indent: 36.0pt;">
<span lang="SV" style="mso-ansi-language: SV;">Stroke ini
menyebabkan berbagai defisit neurologik, bergantung pada lokasi lesi (pembuluh
darah mana yang tersumbat), ukuran area yang perfusinya tidak adekuat, dan
jumlah aliran darah kolateral (sekunder atau aksesori)</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 54.0pt; mso-list: l64 level1 lfo3; tab-stops: list 54.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Kehilangan motorik : hemiplegia (paralisis
pada salah satu sisi) karena lesi pada sesi otak yang berlawanan, hemiparesis
atau kelemahan salah satu sisi tubuh.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 54.0pt; mso-list: l64 level1 lfo3; tab-stops: list 54.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Kehilangan komunikasi : disartria
(kesulitan bicara), disfasia atau afasia (bicara defektif atau kehilangan
bicara), apraksia (ketidakmampuan untuk melakukan tindakan yang dipelajari
sebelumnya)</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 54.0pt; mso-list: l64 level1 lfo3; tab-stops: list 54.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Gangguan persepsi: disfungsi persepsi
visual, gangguan hubungan visual-spasial, kehilangan sensori</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 54.0pt; mso-list: l64 level1 lfo3; tab-stops: list 54.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Kerusakan fungsi kognitif dan efek
psikologis</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 54.0pt; mso-list: l64 level1 lfo3; tab-stops: list 54.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">e.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Disfungsi kandung kemih</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 36.0pt; tab-stops: 54.0pt; text-align: justify; text-indent: 36.0pt;">
<span lang="SV" style="mso-ansi-language: SV;">Gejala - gejala CVA muncul akibat daerah tertentu tidak berfungsi yang
disebabkan oleh terganggunya aliran darah ke tempat tersebut. Gejala itu muncul
bervariasi, bergantung bagian otak yang terganggu. Gejala-gejala itu antara
lain bersifat:</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 54.0pt; mso-list: l64 level2 lfo3; tab-stops: list 54.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="PT-BR" style="mso-ansi-language: PT-BR;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="PT-BR" style="mso-ansi-language: PT-BR;">Sementara<br />
Timbul hanya sebentar selama beberapa menit sampai beberapa jam dan hilang
sendiri dengan atau tanpa pengobatan. Hal ini disebut Transient ischemic attack
(TIA). Serangan bisa muncul lagi dalam wujud sama, memperberat atau malah
menetap.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 54.0pt; mso-list: l64 level2 lfo3; tab-stops: list 54.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="PT-BR" style="mso-ansi-language: PT-BR;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="PT-BR" style="mso-ansi-language: PT-BR;">Sementara,namun lebih dari 24 jam<span style="mso-tab-count: 1;"> </span><br />
Gejala timbul lebih dari 24 jam dan ini dissebut reversible ischemic neurologic
defisit (RIND)</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 54.0pt; mso-list: l64 level2 lfo3; tab-stops: list 54.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="PT-BR" style="mso-ansi-language: PT-BR;"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="PT-BR" style="mso-ansi-language: PT-BR;">Gejala makin lama makin berat
(progresif). Hal ini desebabkan gangguan aliran darah makin lama makin berat
yang disebut progressing stroke atau stroke inevolution.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 54.0pt; mso-list: l64 level2 lfo3; tab-stops: list 54.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Sudah menetap/permanent.</span></div>
<div class="MsoNormal" style="line-height: 150%; tab-stops: 54.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; mso-list: l30 level1 lfo11; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">7.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV;">Komplikasi</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 36.0pt; tab-stops: 36.0pt; text-align: justify;">
<span lang="FI" style="mso-ansi-language: FI;">Komplikasi
utama pada stroke yaitu :</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 54.0pt; mso-list: l118 level1 lfo4; tab-stops: 54.0pt list 72.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Hipoksia Serebral</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 54.0pt; mso-list: l118 level1 lfo4; tab-stops: 54.0pt list 72.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Penurunan darah serebral dan Luasnya area
cedera</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 54.0pt; tab-stops: 54.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; mso-list: l30 level1 lfo11; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">8.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV;">Pemeriksaan Penunjang</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 36.0pt; tab-stops: 36.0pt; text-align: justify; text-indent: 27.0pt;">
<span lang="SV" style="mso-ansi-language: SV;">Pemeriksaan penunjang yang dapat dilakukan untuk menegakkan diagnosa stroke
antara lain adalah:</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 54.0pt; mso-list: l104 level1 lfo5; tab-stops: 36.0pt list 54.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><i style="mso-bidi-font-style: normal;"><span lang="SV" style="mso-ansi-language: SV;">Angiografi</span></i><span lang="SV" style="mso-ansi-language: SV;"><br />
Arteriografi dilakukan untuk memperlihatkan penyebab dan letak gangguan. Suatu
kateter dimasukkan dengan tuntunan fluoroskopi dari arteria femoralis di daerah
inguinal menuju arterial, yang sesuai kemudian zat warna disuntikkan.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 54.0pt; mso-list: l104 level1 lfo5; tab-stops: 36.0pt list 54.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><i style="mso-bidi-font-style: normal;"><span lang="SV" style="mso-ansi-language: SV;">CT-Scan</span></i><span lang="SV" style="mso-ansi-language: SV;"><br />
CT-scan dapat menunjukkan adanya hematoma, infark dan perdarahan.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 54.0pt; mso-list: l104 level1 lfo5; tab-stops: 36.0pt list 54.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><i style="mso-bidi-font-style: normal;"><span lang="SV" style="mso-ansi-language: SV;">EEG
(Elektro Encephalogram)</span></i><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-tab-count: 1;"> </span><br />
Dapat menunjukkan lokasi perdarahan, gelombang delta lebih lambat di daerah
yang mengalami gangguan.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 54.0pt; mso-list: l104 level1 lfo5; tab-stops: 36.0pt list 54.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Pungsi Lumbal</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 54.0pt; tab-stops: 36.0pt list 54.0pt; text-align: justify;">
<span lang="SV" style="mso-ansi-language: SV;">Menunjukan
adanya tekanan normal, tekanan meningkat dan cairan yang mengandung darah
menunjukan adanya perdarahan.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 54.0pt; mso-list: l104 level1 lfo5; tab-stops: 36.0pt list 54.0pt 90.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">e.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><i style="mso-bidi-font-style: normal;"><span lang="SV" style="mso-ansi-language: SV;">MRI</span></i><span lang="SV" style="mso-ansi-language: SV;"> : Menunjukan daerah yang mengalami
infark, hemoragik.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 54.0pt; mso-list: l104 level1 lfo5; tab-stops: 36.0pt list 54.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">f.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><i style="mso-bidi-font-style: normal;"><span lang="SV" style="mso-ansi-language: SV;">Ultrasonografi
Dopler </span></i><span lang="SV" style="mso-ansi-language: SV;">: Mengidentifikasi
penyakit arteriovena</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 54.0pt; mso-list: l104 level1 lfo5; tab-stops: 36.0pt list 54.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">g.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Sinar X Tengkorak : Menggambarkan
perubahan kelenjar lempeng pineal (Doenges E, Marilynn,2000 hal 292).</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 54.0pt; tab-stops: 36.0pt; text-align: justify;">
<br /></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-left: 35.45pt; mso-add-space: auto; mso-list: l30 level1 lfo11; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">9.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV;">Penatalaksanaan</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; text-align: justify;">
<span lang="EN-US" style="mso-fareast-language: IN;">Untuk mengobati keadaan
akut perlu diperhatikan faktor-faktor kritis sebagai berikut</span><span style="mso-ansi-language: IN; mso-fareast-language: IN;"></span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 2.0cm; mso-add-space: auto; mso-list: l98 level1 lfo119; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-language: IN;">Berusaha menstabilkan tanda-tanda vital dengan :</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 70.9pt; mso-add-space: auto; mso-list: l16 level1 lfo120; mso-pagination: none; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><span style="mso-list: Ignore;">1)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-language: IN;">Mempertahankan saluran nafas yang paten yaitu lakukan pengisapan lendiryang
sering, oksigenasi, kalau perlu lakukan trakeostomi, membantu pernafasan.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 70.9pt; mso-add-space: auto; mso-list: l16 level1 lfo120; mso-pagination: none; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><span style="mso-list: Ignore;">2)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Mengontrol tekanan darah berdasarkan
kondisi pasien, termasuk usaha memperbaiki hipotensi dan hipertensi.</span><span lang="EN-US" style="mso-fareast-language: IN;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 70.9pt; mso-add-space: auto; mso-list: l16 level1 lfo120; mso-pagination: none; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><span style="mso-list: Ignore;">3)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Berusaha menemukan dan memperbaiki
aritmia jantung.</span><span lang="EN-US" style="mso-fareast-language: IN;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 70.9pt; mso-add-space: auto; mso-list: l16 level1 lfo120; mso-pagination: none; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><span style="mso-list: Ignore;">4)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Merawat kandung kemih, sedapat
mungkin jangan memakai kateter.</span><span lang="EN-US" style="mso-fareast-language: IN;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 70.9pt; mso-add-space: auto; mso-list: l16 level1 lfo120; mso-pagination: none; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><span style="mso-list: Ignore;">5)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Menempatkan pasien dalam posisi yang
tepat, harus dilakukan secepat mungkin pasien harus dirubah posisi tiap 2 jam
dan dilakukan latihan-latihan gerak pasif.</span><span lang="EN-US" style="mso-fareast-language: IN;"></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 70.9pt; mso-add-space: auto; mso-pagination: none; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; mso-list: l5 level1 lfo12; tab-stops: 18.0pt; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">B.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV;">Konsep Dasar Keperawatan</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; mso-list: l46 level1 lfo13; tab-stops: 18.0pt; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV;">Pengkajian</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 49.65pt; mso-list: l2 level2 lfo15; text-align: justify; text-indent: -14.15pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pengkajian Primer</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l78 level1 lfo14; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><i style="mso-bidi-font-style: normal;"><span lang="EN-US">Airway</span></i></div>
<div class="MsoBodyTextIndent2" style="margin-left: 70.9pt;">
<span lang="EN-US">Adanya
sumbatan/obstruksi jalan napas oleh adanya penumpukan sekret akibat kelemahan
reflek batuk</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l78 level1 lfo14; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><i style="mso-bidi-font-style: normal;"><span lang="EN-US">Breathing</span></i></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; text-align: justify;">
<span lang="EN-US">Kelemahan menelan/ batuk/ melindungi jalan napas,
timbulnya pernapasan yang sulit dan / atau tak teratur, suara nafas terdengar
ronchi /aspirasi</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l78 level1 lfo14; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><i style="mso-bidi-font-style: normal;"><span lang="EN-US">Circulation</span></i></div>
<div class="MsoBodyTextIndent2" style="margin-left: 70.9pt;">
<span lang="EN-US">TD
dapat normal atau meningkat , hipotensi terjadi pada tahap lanjut, takikardi,
bunyi jantung normal pada tahap dini, disritmia, kulit dan membran mukosa
pucat, dingin, sianosis pada tahap lanjut</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-left: 49.65pt; mso-add-space: auto; mso-list: l2 level2 lfo15; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pengkajian Sekunder</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l31 level1 lfo16; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">1)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Aktivitas dan istirahat</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; text-align: justify;">
<span lang="EN-US">Data Subyektif:</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l78 level1 lfo14; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">kesulitan dalam beraktivitas ;
kelemahan, kehilangan sensasi atau paralysis.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l78 level1 lfo14; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">mudah lelah, kesulitan
istirahat ( nyeri atau kejang otot )</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; text-align: justify;">
<span lang="EN-US">Data obyektif:</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 70.9pt; mso-add-space: auto; mso-list: l117 level1 lfo121; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Perubahan tingkat kesadaran </span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 70.9pt; mso-add-space: auto; mso-list: l117 level1 lfo121; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Perubahan tonus otot<span style="mso-spacerun: yes;"> </span>( flaksid atau spastic),<span style="mso-spacerun: yes;"> </span>paraliysis ( hemiplegia ) ,kelemahan umum.</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 70.9pt; mso-add-space: auto; mso-list: l117 level1 lfo121; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">gangguan penglihatan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l31 level1 lfo16; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">2)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Sirkulasi</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 57.05pt; text-align: justify; text-indent: 13.85pt;">
<span lang="EN-US">Data Subyektif:</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l78 level3 lfo14; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Riwayat penyakit jantung (<span style="mso-spacerun: yes;"> </span>penyakit katup jantung, disritmia, gagal
jantung , endokarditis bacterial ), polisitemia.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 54.9pt; text-align: justify; text-indent: 16.0pt;">
<span lang="EN-US">Data obyektif:</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l78 level3 lfo14; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Hipertensi arterial</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l78 level3 lfo14; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Disritmia, perubahan EKG</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l78 level3 lfo14; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pulsasi : kemungkinan
bervariasi </span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l78 level3 lfo14; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Denyut karotis, femoral dan
arteri iliaka atau aorta abdominal</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l31 level1 lfo16; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">3)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Integritas ego</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; text-align: justify;">
<span lang="EN-US">Data Subyektif:</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l78 level1 lfo14; text-align: justify; text-indent: -14.7pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Perasaan tidak berdaya, hilang
harapan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; text-align: justify;">
<span lang="EN-US">Data obyektif:</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l78 level1 lfo14; text-align: justify; text-indent: -14.15pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Emosi yang labil dan marah yang
tidak tepat, kesediahan , kegembiraan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l78 level1 lfo14; text-align: justify; text-indent: -14.15pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">kesulitan berekspresi diri</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l31 level1 lfo16; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">4)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Eliminasi</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; text-align: justify;">
<span lang="EN-US">Data Subyektif:</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l78 level1 lfo14; text-align: justify; text-indent: -14.15pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Inkontinensia, anuria</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l78 level1 lfo14; text-align: justify; text-indent: -14.15pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">distensi abdomen ( kandung
kemih sangat penuh ),<span style="mso-spacerun: yes;"> </span>tidak adanya suara
usus( ileus paralitik )</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l31 level1 lfo16; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">5)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Makan/ minum</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; text-align: justify;">
<span lang="EN-US">Data Subyektif:</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l78 level1 lfo14; text-align: justify; text-indent: -14.15pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Nafsu makan hilang</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l78 level1 lfo14; text-align: justify; text-indent: -14.15pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Nausea / vomitus menandakan
adanya PTIK</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l78 level1 lfo14; text-align: justify; text-indent: -14.15pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Kehilangan sensasi lidah , pipi
, tenggorokan, disfagia</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l78 level1 lfo14; text-align: justify; text-indent: -14.15pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Riwayat DM, Peningkatan lemak
dalam darah</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; text-align: justify;">
<span lang="EN-US">Data obyektif:</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l78 level1 lfo14; text-align: justify; text-indent: -14.15pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Problem dalam mengunyah (
menurunnya reflek palatum dan faring )</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l78 level1 lfo14; text-align: justify; text-indent: -14.15pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Obesitas ( factor resiko )</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l31 level1 lfo16; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">6)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Sensori neural </span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; text-align: justify;">
<span lang="EN-US">Data Subyektif:</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l78 level1 lfo14; text-align: justify; text-indent: -18.7pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pusing / syncope<span style="mso-spacerun: yes;"> </span>( sebelum CVA / sementara selama TIA )</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l78 level1 lfo14; text-align: justify; text-indent: -18.7pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">nyeri kepala : pada perdarahan
intra serebral<span style="mso-spacerun: yes;"> </span>atau perdarahan sub
arachnoid.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l78 level1 lfo14; text-align: justify; text-indent: -18.7pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Kelemahan, kesemutan/kebas,
sisi yang terkena terlihat seperti lumpuh/mati</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l78 level1 lfo14; text-align: justify; text-indent: -18.7pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Penglihatan berkurang</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l78 level1 lfo14; text-align: justify; text-indent: -18.7pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Sentuhan<span style="mso-spacerun: yes;"> </span>: kehilangan sensor pada sisi kolateral pada
ekstremitas dan pada muka ipsilateral ( sisi yang sama )</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l78 level1 lfo14; text-align: justify; text-indent: -18.7pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Gangguan rasa pengecapan dan
penciuman</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 49.65pt; text-align: justify; text-indent: 23.85pt;">
<span lang="EN-US">Data obyektif:</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l105 level1 lfo17; text-align: justify; text-indent: -14.7pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Status mental ; koma biasanya
menandai stadium perdarahan , gangguan tingkah laku (seperti: letergi, apatis,
menyerang) dan gangguan fungsi kognitif</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l105 level1 lfo17; text-align: justify; text-indent: -14.7pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Ekstremitas : kelemahan /
paraliysis ( kontralateral pada semua jenis stroke, genggaman tangan tidak
imbang, berkurangnya reflek tendon dalam<span style="mso-spacerun: yes;">
</span>( kontralateral )</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l105 level1 lfo17; text-align: justify; text-indent: -14.7pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Wajah: paralisis / parese (
ipsilateral )</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l105 level1 lfo17; text-align: justify; text-indent: -14.7pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Afasia<span style="mso-spacerun: yes;"> </span>( kerusakan atau kehilangan fungsi bahasa,
kemungkinan ekspresif/ kesulitan berkata kata, reseptif / kesulitan berkata
kata komprehensif, global / kombinasi dari keduanya.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l105 level1 lfo17; text-align: justify; text-indent: -14.7pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Kehilangan kemampuan mengenal
atau melihat, pendengaran, stimuli taktil</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l105 level1 lfo17; text-align: justify; text-indent: -14.7pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Apraksia : kehilangan kemampuan
menggunakan motorik</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l78 level1 lfo14; text-align: justify; text-indent: -14.15pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Reaksi dan ukuran pupil : tidak
sama dilatasi dan tak bereaksi pada sisi ipsi lateral</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l31 level1 lfo16; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">7)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Nyeri / kenyamanan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; text-align: justify;">
<span lang="EN-US">Data Subyektif:</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l78 level1 lfo14; text-align: justify; text-indent: -14.7pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Sakit kepala yang bervariasi
intensitasnya</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 49.65pt; text-align: justify; text-indent: 21.3pt;">
<span lang="EN-US">Data obyektif:</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 70.9pt; mso-list: l78 level1 lfo14; text-align: justify; text-indent: -14.7pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Tingkah laku yang tidak stabil,
gelisah, ketegangan otot / fasial</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; tab-stops: 18.0pt 27.0pt; text-align: justify; text-indent: -36.0pt;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; tab-stops: 18.0pt 27.0pt; text-align: justify; text-indent: -36.0pt;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; tab-stops: 18.0pt 27.0pt; text-align: justify; text-indent: -36.0pt;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; tab-stops: 18.0pt 27.0pt; text-align: justify; text-indent: -36.0pt;">
<br /></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-left: 35.45pt; mso-add-space: auto; mso-layout-grid-align: none; mso-list: l46 level1 lfo13; text-align: justify; text-autospace: none; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV;">Diagnosa Keperawatan</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 54.0pt; mso-layout-grid-align: none; mso-list: l100 level1 lfo7; text-align: justify; text-autospace: none; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Ketidakefektifan
pembersihan jalan napas berhubungan dengan akumulasi skret sekunder adanya
kelemahan neuromuskuler.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 54.0pt; mso-layout-grid-align: none; mso-list: l100 level1 lfo7; text-align: justify; text-autospace: none; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Ketidakefektifan
perfusi jaringan cerebral berhubungan dengangangguan aliran arteri atau vena</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 54.0pt; mso-layout-grid-align: none; mso-list: l100 level1 lfo7; text-align: justify; text-autospace: none; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Ketidakseimbangan
cairan dan elektrolit: kurang dari yang dibutuhkan berhubungan dengan intake
yang tidak adequate.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 54.0pt; mso-layout-grid-align: none; mso-list: l100 level1 lfo7; text-align: justify; text-autospace: none; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Ketidakseimbangan nutrisi
kurang dari kebutuhan tubuh berhubungan dengan kesulitan menelan dan mengunyah</span><span lang="SV" style="mso-ansi-language: SV;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 54.0pt; mso-layout-grid-align: none; mso-list: l100 level1 lfo7; text-align: justify; text-autospace: none; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">e.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Intoleransi
aktifvitas berhubungan dengan </span><span lang="EN-US">ketidakseimbangan antara
suplay oksigen dengan kebutuhan</span><span lang="SV" style="mso-ansi-language: SV;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 54.0pt; mso-layout-grid-align: none; mso-list: l100 level1 lfo7; text-align: justify; text-autospace: none; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">f.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Gangguan
komunikasi verbal berhubungn dengan gangguan pada N. Fasialis</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 54.0pt; mso-layout-grid-align: none; mso-list: l100 level1 lfo7; text-align: justify; text-autospace: none; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">g.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Defisit
perawatan diri berhubungan dengan intoleransi aktivitas</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 54.0pt; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; mso-layout-grid-align: none; tab-stops: 36.0pt; text-align: justify; text-autospace: none;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; mso-layout-grid-align: none; tab-stops: 36.0pt; text-align: justify; text-autospace: none;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; mso-layout-grid-align: none; tab-stops: 18.0pt 36.0pt; text-align: justify; text-autospace: none;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; mso-layout-grid-align: none; tab-stops: 18.0pt 36.0pt; text-align: justify; text-autospace: none;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; mso-layout-grid-align: none; tab-stops: 18.0pt 36.0pt; text-align: justify; text-autospace: none;">
<br /></div>
</div>
<span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: SV; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;"><br clear="all" style="mso-break-type: section-break; page-break-before: auto;" />
</span>
<div class="WordSection4">
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: none; margin-left: -25.7pt; mso-border-alt: solid windowtext .5pt; mso-border-insideh: .5pt solid windowtext; mso-border-insidev: .5pt solid windowtext; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-table-layout-alt: fixed; width: 1008px;">
<tbody>
<tr style="height: 18.0pt; mso-yfti-firstrow: yes; mso-yfti-irow: 0; page-break-inside: avoid;">
<td rowspan="2" style="border: solid windowtext 1.0pt; height: 18.0pt; mso-border-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 31.1pt;" valign="top" width="41">
<div align="center" class="MsoNormal" style="line-height: 150%; margin-right: -2.9pt; text-align: center;">
<b><span style="mso-ansi-language: IN;">N</span></b></div>
<div align="center" class="MsoNormal" style="line-height: 150%; margin-right: -2.9pt; text-align: center;">
<b><span style="mso-ansi-language: IN;">O</span></b></div>
</td>
<td rowspan="2" style="border-left: none; border: solid windowtext 1.0pt; height: 18.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 229.5pt;" valign="top" width="306">
<div align="center" class="MsoNormal" style="line-height: 150%; margin-right: -2.9pt; text-align: center;">
<b><span lang="EN-US">Diagnosa Keperawatan/ Masalah
Kolaborasi</span></b></div>
</td>
<td colspan="4" style="border-left: none; border: solid windowtext 1.0pt; height: 18.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 495.55pt;" valign="top" width="661">
<div align="center" class="MsoNormal" style="line-height: 150%; margin-right: -2.9pt; text-align: center;">
<b><span style="mso-ansi-language: IN;">NURSE CARE PLANING</span></b></div>
</td>
</tr>
<tr style="height: 18.0pt; mso-row-margin-right: 1.8pt; mso-yfti-irow: 1; page-break-inside: avoid;">
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 18.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 238.3pt;" valign="top" width="318">
<div align="center" class="MsoNormal" style="line-height: 150%; margin-right: -2.9pt; text-align: center;">
<b><span style="mso-ansi-language: IN;">NOC</span></b></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 18.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.45pt;" valign="top" width="341">
<div align="center" class="MsoNormal" style="line-height: 150%; margin-right: -2.9pt; text-align: center;">
<b><span style="mso-ansi-language: IN;">NIC</span></b></div>
</td>
<td colspan="2" style="border: none; mso-cell-special: placeholder; padding: 0cm 0cm 0cm 0cm;" width="2"><div class="MsoNormal">
<br /></div>
</td>
</tr>
<tr style="height: 98.75pt; mso-row-margin-right: 1.8pt; mso-yfti-irow: 2;">
<td style="border-top: none; border: solid windowtext 1.0pt; height: 98.75pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 31.1pt;" valign="top" width="41">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">1</span></b></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 98.75pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 229.5pt;" valign="top" width="306">
<div class="MsoNormal" style="line-height: 150%;">
<b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV;">Bersihan Jalan Nafas tidak
efektif </span></b><span lang="SV" style="mso-ansi-language: SV;">berhubungan
dengan: </span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 10.65pt; mso-list: l63 level1 lfo18; tab-stops: list 10.65pt; text-indent: -10.65pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-spacerun: yes;"> </span>Infeksi, disfungsi neuromuskular,
hiperplasia dinding bronkus, alergi jalan nafas, asma, trauma</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 10.65pt; mso-list: l63 level1 lfo18; tab-stops: list 10.65pt; text-indent: -10.65pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Obstruksi jalan nafas : spasme jalan nafas,
sekresi tertahan, banyaknya mukus, adanya jalan nafas buatan, sekresi
bronkus, adanya eksudat di alveolus, adanya benda asing di jalan nafas.</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="NO-BOK" style="mso-ansi-language: NO-BOK;">DS:</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 10.65pt; mso-list: l63 level1 lfo18; tab-stops: list 10.65pt 36.0pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="mso-ansi-language: NO-BOK;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NO-BOK" style="mso-ansi-language: NO-BOK;">Dispneu</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="NO-BOK" style="mso-ansi-language: NO-BOK;">DO:</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 10.65pt; mso-list: l63 level1 lfo18; tab-stops: list 10.6pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="mso-ansi-language: NO-BOK;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NO-BOK" style="mso-ansi-language: NO-BOK;">Penurunan suara nafas</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 10.65pt; mso-list: l63 level1 lfo18; tab-stops: list 10.6pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="mso-ansi-language: NO-BOK;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NO-BOK" style="mso-ansi-language: NO-BOK;">Orthopneu</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 10.65pt; mso-list: l63 level1 lfo18; tab-stops: list 10.6pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="mso-ansi-language: NO-BOK;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NO-BOK" style="mso-ansi-language: NO-BOK;">Cyanosis</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 10.65pt; mso-list: l63 level1 lfo18; tab-stops: list 10.6pt; text-indent: -9.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Kelainan suara nafas (rales,
wheezing)</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 10.65pt; mso-list: l63 level1 lfo18; tab-stops: list 10.6pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="mso-ansi-language: NO-BOK;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NO-BOK" style="mso-ansi-language: NO-BOK;">Kesulitan berbicara</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 10.65pt; mso-list: l63 level1 lfo18; tab-stops: list 10.6pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="mso-ansi-language: NO-BOK;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NO-BOK" style="mso-ansi-language: NO-BOK;">Batuk, tidak efekotif atau tidak
ada</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 10.65pt; mso-list: l63 level1 lfo18; tab-stops: list 10.6pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="mso-ansi-language: NO-BOK;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NO-BOK" style="mso-ansi-language: NO-BOK;">Produksi sputum</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 10.65pt; mso-list: l63 level1 lfo18; tab-stops: list 10.6pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="mso-ansi-language: NO-BOK;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NO-BOK" style="mso-ansi-language: NO-BOK;">Gelisah</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 10.65pt; mso-list: l63 level1 lfo18; tab-stops: list 10.6pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="mso-ansi-language: NO-BOK;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NO-BOK" style="mso-ansi-language: NO-BOK;">Perubahan frekuensi dan irama
nafas</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 98.75pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 238.3pt;" valign="top" width="318">
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US">NOC:</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 13.95pt; mso-list: l112 level1 lfo19; tab-stops: list 13.95pt 81.0pt; text-indent: -13.95pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Respiratory status : Ventilation</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 13.95pt; mso-list: l112 level1 lfo19; tab-stops: list 13.95pt 81.0pt; text-indent: -13.95pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Respiratory status : Airway patency</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 13.95pt; mso-list: l112 level1 lfo19; tab-stops: list 13.95pt 81.0pt; text-indent: -13.95pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Aspiration Control</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US">Setelah
dilakukan tindakan keperawatan selama …………..pasien menunjukkan keefektifan
jalan nafas dibuktikan dengan kriteria hasil :</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 13.95pt; mso-list: l115 level1 lfo20; tab-stops: list 13.95pt 18.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Mendemonstrasikan batuk efektif dan suara nafas yang bersih, tidak
ada sianosis dan dyspneu (mampu mengeluarkan sputum, bernafas dengan mudah,
tidak ada pursed lips)</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 13.95pt; mso-list: l115 level1 lfo20; tab-stops: list 13.95pt 18.0pt 39.55pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Menunjukkan jalan nafas yang paten (klien tidak merasa tercekik,
irama nafas, frekuensi pernafasan dalam rentang normal, tidak ada suara nafas
abnormal)</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 13.95pt; mso-list: l115 level1 lfo20; tab-stops: list 13.95pt 18.0pt 39.55pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Mampu mengidentifikasikan dan mencegah faktor yang penyebab.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 13.95pt; mso-list: l115 level1 lfo20; tab-stops: list 13.95pt 18.0pt 39.55pt; text-align: justify; text-indent: -18.0pt;">
<span lang="NL" style="font-family: Wingdings; mso-ansi-language: NL; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="mso-ansi-language: NL;">Saturasi O2 dalam batas normal</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 13.95pt; mso-list: l115 level1 lfo20; tab-stops: list 13.95pt 18.0pt 39.55pt; text-align: justify; text-indent: -18.0pt;">
<span lang="PT-BR" style="font-family: Wingdings; mso-ansi-language: PT-BR; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="PT-BR" style="mso-ansi-language: PT-BR;">Foto thorak dalam batas normal</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 98.75pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.45pt;" valign="top" width="341">
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 6.7pt; mso-list: l26 level1 lfo22; tab-stops: list 6.7pt; text-align: justify; text-indent: -9.0pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Pastikan kebutuhan oral / tracheal suctioning.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 6.7pt; mso-list: l26 level1 lfo22; tab-stops: list 6.7pt; text-indent: -9.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Berikan O2<span style="mso-spacerun: yes;"> </span>……l/mnt, metode………</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 6.7pt; mso-list: l26 level1 lfo22; tab-stops: list 6.7pt; text-align: justify; text-indent: -9.0pt;">
<span lang="FI" style="font-family: Wingdings; mso-ansi-language: FI; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Anjurkan pasien untuk istirahat dan
napas dalam </span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 6.7pt; mso-list: l77 level1 lfo21; tab-stops: list 6.7pt; text-align: justify; text-indent: -9.0pt;">
<span lang="NL" style="font-family: Symbol; mso-ansi-language: NL; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="mso-ansi-language: NL;">Posisikan pasien untuk memaksimalkan
ventilasi</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 6.7pt; mso-list: l77 level1 lfo21; tab-stops: list 6.7pt; text-align: justify; text-indent: -9.0pt;">
<span lang="FR" style="font-family: Symbol; mso-ansi-language: FR; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FR" style="mso-ansi-language: FR;">Lakukan fisioterapi dada jika perlu</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 6.7pt; mso-list: l77 level1 lfo21; tab-stops: list 6.7pt; text-align: justify; text-indent: -9.0pt;">
<span lang="SV" style="font-family: Symbol; mso-ansi-language: SV; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Keluarkan sekret dengan batuk atau suction</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 6.7pt; mso-list: l77 level1 lfo21; tab-stops: list 6.7pt; text-align: justify; text-indent: -9.0pt;">
<span lang="FR" style="font-family: Symbol; mso-ansi-language: FR; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FR" style="mso-ansi-language: FR;">Auskultasi suara nafas, catat adanya
suara tambahan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 6.7pt; mso-list: l77 level1 lfo21; tab-stops: list 6.7pt; text-align: justify; text-indent: -9.0pt;">
<span lang="FR" style="font-family: Symbol; mso-ansi-language: FR; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FR" style="mso-ansi-language: FR;">Berikan bronkodilator :</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 6.7pt; mso-list: l77 level1 lfo21; tab-stops: list 6.7pt; text-align: justify; text-indent: -9.0pt;">
<span lang="FR" style="font-family: Symbol; mso-ansi-language: FR; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FR" style="mso-ansi-language: FR;">Monitor status hemodinamik</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 6.7pt; mso-list: l77 level1 lfo21; tab-stops: list 6.7pt; text-align: justify; text-indent: -9.0pt;">
<span lang="SV" style="font-family: Symbol; mso-ansi-language: SV; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Berikan pelembab udara Kassa basah NaCl
Lembab</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 6.7pt; mso-list: l77 level1 lfo21; tab-stops: list 6.7pt; text-align: justify; text-indent: -9.0pt;">
<span lang="FR" style="font-family: Symbol; mso-ansi-language: FR; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FR" style="mso-ansi-language: FR;">Berikan antibiotik :</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 6.7pt; mso-list: l77 level1 lfo21; tab-stops: list 6.7pt 81.0pt; text-align: justify; text-indent: -9.0pt;">
<span lang="FI" style="font-family: Symbol; mso-ansi-language: FI; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Atur intake untuk cairan mengoptimalkan
keseimbangan.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 6.7pt; mso-list: l77 level1 lfo21; tab-stops: list 6.7pt 81.0pt; text-align: justify; text-indent: -9.0pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FR" style="mso-ansi-language: FR;">Monitor respirasi dan status O2</span><span lang="EN-US"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 6.7pt; mso-list: l77 level1 lfo21; tab-stops: list 6.7pt 81.0pt; text-align: justify; text-indent: -9.0pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FR" style="mso-ansi-language: FR;">Pertahankan hidrasi yang adekuat untuk
mengencerkan sekret</span><span lang="EN-US"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 6.7pt; mso-list: l77 level1 lfo21; tab-stops: list 6.7pt 81.0pt; text-align: justify; text-indent: -9.0pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Jelaskan pada pasien dan keluarga tentang penggunaan
peralatan : O2, Suction, Inhalasi.</span></div>
</td>
<td colspan="2" style="border: none; mso-cell-special: placeholder; padding: 0cm 0cm 0cm 0cm;" width="2"><div class="MsoNormal">
<br /></div>
</td>
</tr>
<tr style="height: 70.4pt; mso-row-margin-right: 1.8pt; mso-yfti-irow: 3;">
<td style="border-top: none; border: solid windowtext 1.0pt; height: 70.4pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 31.1pt;" valign="top" width="41">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">2</span></b></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 70.4pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 229.5pt;" valign="top" width="306">
<div class="MsoNormal" style="line-height: 150%;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Perfusi jaringan cerebral tidak efektif</span></b><span lang="EN-US"> b/d gangguan afinitas Hb oksigen, penurunan konsentrasi Hb,
Hipervolemia, Hipoventilasi, gangguan transport O2, gangguan aliran arteri
dan vena</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="NO-BOK" style="mso-ansi-language: NO-BOK;">DO </span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 10.65pt; mso-list: l63 level1 lfo18; tab-stops: list 10.65pt 36.0pt; text-indent: -9.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Gangguan status mental</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 10.65pt; mso-list: l63 level1 lfo18; tab-stops: list 10.65pt 36.0pt; text-indent: -9.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Perubahan perilaku</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 10.65pt; mso-list: l63 level1 lfo18; tab-stops: list 10.65pt 36.0pt; text-indent: -9.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Perubahan respon motorik</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 10.65pt; mso-list: l63 level1 lfo18; tab-stops: list 10.65pt 36.0pt; text-indent: -9.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Perubahan reaksi pupil</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 10.65pt; mso-list: l63 level1 lfo18; tab-stops: list 10.65pt 36.0pt; text-indent: -9.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Kesulitan menelan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 10.65pt; mso-list: l63 level1 lfo18; tab-stops: list 10.65pt 36.0pt; text-indent: -9.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Kelemahan atau paralisis
ekstrermitas</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 10.65pt; mso-list: l63 level1 lfo18; tab-stops: list 10.65pt 36.0pt; text-indent: -9.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Abnormalitas bicara</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 70.4pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 238.3pt;" valign="top" width="318">
<div class="MsoNormal" style="line-height: 150%;">
<b><span lang="EN-US">NOC :</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 22.05pt; mso-list: l97 level3 lfo23; tab-stops: list 156.0pt; text-indent: -18.35pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Circulation status</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 22.05pt; mso-list: l97 level3 lfo23; tab-stops: list 156.0pt; text-indent: -18.35pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Neurologic status</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 22.05pt; mso-list: l97 level3 lfo23; tab-stops: list 156.0pt; text-indent: -18.35pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Tissue Prefusion : cerebral</span></div>
<div class="MsoNormal" style="line-height: 150%; tab-stops: list 192.0pt;">
<span lang="EN-US" style="mso-bidi-font-weight: bold;">Setelah dilakukan asuhan
selama………ketidakefektifan perfusi jaringan cerebral teratasi dengan kriteria
hasil</span><span lang="NL" style="mso-ansi-language: NL;">:</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 22.8pt; mso-list: l45 level1 lfo24; tab-stops: list 90.0pt 108.0pt; text-indent: -18.0pt;">
<span lang="NL" style="font-family: Wingdings; mso-ansi-language: NL; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="mso-ansi-language: NL;">Tekanan systole dan diastole dalam
rentang yang diharapkan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 22.8pt; mso-list: l45 level1 lfo24; tab-stops: list 90.0pt 108.0pt 135.0pt; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Tidak ada ortostatikhipertensi</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 22.8pt; mso-list: l45 level1 lfo24; tab-stops: list 90.0pt 108.0pt 135.0pt; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Komunikasi jelas</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 22.8pt; mso-list: l45 level1 lfo24; tab-stops: list 90.0pt 108.0pt 135.0pt; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Menunjukkan konsentrasi dan orientasi</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 22.8pt; mso-list: l45 level1 lfo24; tab-stops: list 90.0pt 108.0pt 135.0pt; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Pupil seimbang dan reaktif</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 22.8pt; mso-list: l45 level1 lfo24; tab-stops: list 90.0pt 108.0pt 135.0pt; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Bebas dari aktivitas kejang</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 22.8pt; mso-list: l45 level1 lfo24; tab-stops: list 90.0pt 108.0pt 135.0pt; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Tidak mengalami nyeri kepala</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 70.4pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.45pt;" valign="top" width="341">
<div class="MsoBodyTextIndent2" style="margin-left: 0cm;">
<b><span lang="EN-US">NIC :</span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US"></span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.65pt; mso-list: l68 level1 lfo25; tab-stops: list 36.0pt; text-indent: -18.0pt;">
<span lang="FI" style="font-family: Wingdings; mso-ansi-language: FI; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Monitor TTV</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.65pt; mso-list: l68 level1 lfo25; tab-stops: list 36.0pt; text-indent: -18.0pt;">
<span lang="FI" style="font-family: Wingdings; mso-ansi-language: FI; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Monitor AGD, ukuran pupil, ketajaman,
kesimetrisan dan reaksi</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.65pt; mso-list: l68 level1 lfo25; tab-stops: list 36.0pt; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Monitor adanya diplopia, pandangan
kabur, nyeri kepala</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.65pt; mso-list: l68 level1 lfo25; tab-stops: list 36.0pt; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Monitor level kebingungan dan orientasi</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.65pt; mso-list: l68 level1 lfo25; tab-stops: list 36.0pt; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Monitor tonus otot pergerakan </span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.65pt; mso-list: l68 level1 lfo25; tab-stops: list 36.0pt; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Monitor tekanan intrkranial dan respon
nerologis</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.65pt; mso-list: l68 level1 lfo25; tab-stops: list 36.0pt; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Catat perubahan pasien dalam merespon stimulus</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.65pt; mso-list: l68 level1 lfo25; tab-stops: list 36.0pt; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Monitor status cairan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.65pt; mso-list: l68 level1 lfo25; tab-stops: list 36.0pt; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Pertahankan parameter hemodinamik</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.65pt; mso-list: l68 level1 lfo25; tab-stops: list 36.0pt; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Tinggikan kepala 0-45<sup>o</sup>
tergantung pada konsisi pasien dan order medis</span></div>
</td>
<td colspan="2" style="border: none; mso-cell-special: placeholder; padding: 0cm 0cm 0cm 0cm;" width="2"><div class="MsoNormal">
<br /></div>
</td>
</tr>
<tr style="height: 170.75pt; mso-row-margin-right: .3pt; mso-yfti-irow: 4;">
<td style="border-top: none; border: solid windowtext 1.0pt; height: 170.75pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 31.1pt;" valign="top" width="41">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">3</span></b></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 170.75pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 229.5pt;" valign="top" width="306">
<div class="MsoNormal" style="line-height: 150%;">
<b style="mso-bidi-font-weight: normal;"><span lang="FI" style="mso-ansi-language: FI;">Ketidakseimbangan nutrisi
kurang dari kebutuhan tubuh</span></b></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="SV" style="mso-ansi-language: SV;">Berhubungan dengan : </span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="SV" style="mso-ansi-language: SV;">Ketidakmampuan untuk memasukkan atau mencerna nutrisi oleh karena faktor
biologis, psikologis atau ekonomi. </span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="NO-BOK" style="mso-ansi-language: NO-BOK;">DS:</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 13.95pt; mso-list: l63 level1 lfo18; tab-stops: list 13.95pt; text-align: justify; text-indent: -9.0pt;">
<span lang="NO-BOK" style="mso-ansi-language: NO-BOK;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NO-BOK" style="mso-ansi-language: NO-BOK;">Nyeri abdomen</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 13.95pt; mso-list: l63 level1 lfo18; tab-stops: list 13.95pt; text-align: justify; text-indent: -9.0pt;">
<span lang="NO-BOK" style="mso-ansi-language: NO-BOK;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NO-BOK" style="mso-ansi-language: NO-BOK;">Muntah</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 13.95pt; mso-list: l63 level1 lfo18; tab-stops: list 13.95pt; text-align: justify; text-indent: -9.0pt;">
<span lang="NO-BOK" style="mso-ansi-language: NO-BOK;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NO-BOK" style="mso-ansi-language: NO-BOK;">Kejang perut</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 13.95pt; mso-list: l63 level1 lfo18; tab-stops: list 13.95pt; text-align: justify; text-indent: -9.0pt;">
<span lang="NO-BOK" style="mso-ansi-language: NO-BOK;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NO-BOK" style="mso-ansi-language: NO-BOK;">Rasa penuh tiba-tiba setelah
makan</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="NO-BOK" style="mso-ansi-language: NO-BOK;">DO:</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 13.85pt; mso-list: l63 level1 lfo18; tab-stops: list 13.95pt; text-align: justify; text-indent: -9.0pt;">
<span lang="NO-BOK" style="mso-ansi-language: NO-BOK;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NO-BOK" style="mso-ansi-language: NO-BOK;">Diare</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 13.85pt; mso-list: l63 level1 lfo18; tab-stops: list 13.95pt; text-align: justify; text-indent: -9.0pt;">
<span lang="NO-BOK" style="mso-ansi-language: NO-BOK;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NO-BOK" style="mso-ansi-language: NO-BOK;">Rontok rambut yang berlebih</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 13.85pt; mso-list: l63 level1 lfo18; tab-stops: list 13.95pt; text-align: justify; text-indent: -9.0pt;">
<span lang="NO-BOK" style="mso-ansi-language: NO-BOK;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NO-BOK" style="mso-ansi-language: NO-BOK;">Kurang nafsu makan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 13.85pt; mso-list: l63 level1 lfo18; tab-stops: list 13.95pt; text-align: justify; text-indent: -9.0pt;">
<span lang="NO-BOK" style="mso-ansi-language: NO-BOK;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NO-BOK" style="mso-ansi-language: NO-BOK;">Bising usus berlebih</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 13.85pt; mso-list: l63 level1 lfo18; tab-stops: list 13.95pt; text-align: justify; text-indent: -9.0pt;">
<span lang="NO-BOK" style="mso-ansi-language: NO-BOK;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NO-BOK" style="mso-ansi-language: NO-BOK;">Konjungtiva pucat</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 13.85pt; mso-list: l63 level1 lfo18; tab-stops: list 13.95pt; text-align: justify; text-indent: -9.0pt;">
<span lang="NO-BOK" style="mso-ansi-language: NO-BOK;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NO-BOK" style="mso-ansi-language: NO-BOK;">Denyut nadi lemah</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 170.75pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 238.3pt;" valign="top" width="318">
<div class="MsoNormal" style="line-height: 150%;">
<b><span lang="FI" style="mso-ansi-language: FI;">NOC:</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 14.35pt; mso-list: l26 level2 lfo22; tab-stops: list 14.35pt; text-indent: -14.35pt;">
<span lang="FI" style="mso-ansi-language: FI; mso-bidi-font-weight: bold;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI; mso-bidi-font-weight: bold;">Nutritional status: Adequacy of nutrient</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 14.35pt; mso-list: l26 level2 lfo22; tab-stops: list 14.35pt; text-indent: -14.35pt;">
<span lang="EN-US" style="mso-bidi-font-weight: bold;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Nutritional Status : food and Fluid Intake<span style="mso-bidi-font-weight: bold;"></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 14.35pt; mso-list: l26 level2 lfo22; tab-stops: list 14.35pt; text-indent: -14.35pt;">
<span lang="EN-US" style="mso-bidi-font-weight: bold;"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Weight Control<span style="mso-bidi-font-weight: bold;"></span></span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="FI" style="mso-ansi-language: FI; mso-bidi-font-weight: bold;">Setelah dilakukan tindakan keperawatan
selama….nutrisi kurang teratasi dengan indikator:</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 13.4pt; mso-list: l19 level1 lfo26; tab-stops: list 13.45pt; text-indent: -17.95pt;">
<span style="font-family: Wingdings; mso-ansi-language: IN; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="mso-ansi-language: IN;">Albumin serum</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 13.4pt; mso-list: l19 level1 lfo26; tab-stops: list 13.45pt; text-indent: -17.95pt;">
<span style="font-family: Wingdings; mso-ansi-language: IN; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="mso-ansi-language: IN;">Pre albumin serum</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 13.4pt; mso-list: l19 level1 lfo26; tab-stops: list 13.45pt; text-indent: -17.95pt;">
<span style="font-family: Wingdings; mso-ansi-language: IN; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="mso-ansi-language: IN;">Hematokrit</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 13.4pt; mso-list: l19 level1 lfo26; tab-stops: list 13.45pt; text-indent: -17.95pt;">
<span style="font-family: Wingdings; mso-ansi-language: IN; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="mso-ansi-language: IN;">Hemoglobin</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 13.4pt; mso-list: l19 level1 lfo26; tab-stops: list 13.45pt; text-indent: -17.95pt;">
<span style="font-family: Wingdings; mso-ansi-language: IN; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="mso-ansi-language: IN;">Total iron binding capacity</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 13.4pt; mso-list: l19 level1 lfo26; tab-stops: list 13.45pt; text-indent: -17.95pt;">
<span style="font-family: Wingdings; mso-ansi-language: IN; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="mso-ansi-language: IN;">Jumlah limfosit</span></div>
</td>
<td colspan="2" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 170.75pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 256.95pt;" valign="top" width="343">
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.4pt; mso-list: l87 level1 lfo27; tab-stops: list 4.6pt 36.0pt; text-align: justify; text-indent: -8.55pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Kaji adanya alergi makanan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.4pt; mso-list: l87 level1 lfo27; tab-stops: list 4.6pt 36.0pt; text-align: justify; text-indent: -8.55pt;">
<span lang="NL" style="font-family: Wingdings; mso-ansi-language: NL; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Kolaborasi dengan ahli gizi untuk menentukan jumlah kalori dan
nutrisi yang dibutuhkan pasien</span><span lang="NL" style="mso-ansi-language: NL;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.4pt; mso-list: l87 level1 lfo27; tab-stops: list 4.6pt 36.0pt; text-align: justify; text-indent: -8.55pt;">
<span lang="NL" style="font-family: Wingdings; mso-ansi-language: NL; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="mso-ansi-language: NL;">Yakinkan diet yang dimakan mengandung
tinggi serat untuk mencegah konstipasi</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.4pt; mso-list: l87 level1 lfo27; tab-stops: list 4.6pt 36.0pt; text-align: justify; text-indent: -8.55pt;">
<span lang="FI" style="font-family: Wingdings; mso-ansi-language: FI; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Ajarkan pasien bagaimana membuat catatan
makanan harian.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.4pt; mso-list: l52 level1 lfo28; tab-stops: list 4.6pt 36.0pt; text-align: justify; text-indent: -8.55pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Monitor adanya penurunan BB dan gula
darah</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.4pt; mso-list: l52 level1 lfo28; tab-stops: list 4.6pt 36.0pt; text-align: justify; text-indent: -8.55pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Monitor lingkungan selama makan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.4pt; mso-list: l52 level1 lfo28; tab-stops: list 4.6pt 36.0pt; text-align: justify; text-indent: -8.55pt;">
<span lang="NL" style="font-family: Wingdings; mso-ansi-language: NL; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="mso-ansi-language: NL;">Jadwalkan pengobatan<span style="mso-spacerun: yes;"> </span>dan tindakan tidak selama jam makan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.4pt; mso-list: l52 level1 lfo28; tab-stops: list 4.6pt 36.0pt; text-align: justify; text-indent: -8.55pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Monitor turgor kulit</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.4pt; mso-list: l52 level1 lfo28; tab-stops: list 4.6pt 36.0pt; text-align: justify; text-indent: -8.55pt;">
<span lang="NL" style="font-family: Wingdings; mso-ansi-language: NL; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Monitor kekeringan, rambut kusam,
protein, Hb dan kadar Ht</span><span lang="NL" style="mso-ansi-language: NL;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.4pt; mso-list: l52 level1 lfo28; tab-stops: list 4.6pt 36.0pt; text-align: justify; text-indent: -8.55pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Monitor mual dan muntah</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.4pt; mso-list: l52 level1 lfo28; tab-stops: list 4.6pt 36.0pt; text-align: justify; text-indent: -8.55pt;">
<span lang="NL" style="font-family: Wingdings; mso-ansi-language: NL; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="mso-ansi-language: NL;">Monitor pucat, kemerahan, dan kekeringan
jaringan konjungtiva</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.4pt; mso-list: l52 level1 lfo28; tab-stops: list 4.6pt 36.0pt; text-align: justify; text-indent: -8.55pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Monitor intake nuntrisi</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.4pt; mso-list: l52 level1 lfo28; tab-stops: list 4.6pt 36.0pt; text-align: justify; text-indent: -8.55pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Informasikan pada klien dan keluarga
tentang manfaat nutrisi</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.4pt; mso-list: l52 level1 lfo28; tab-stops: list 4.6pt 36.0pt; text-align: justify; text-indent: -8.55pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Kolaborasi dengan dokter tentang
kebutuhan suplemen makanan seperti NGT/ TPN sehingga intake cairan yang
adekuat dapat dipertahankan.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.4pt; mso-list: l52 level1 lfo28; tab-stops: list 4.6pt 36.0pt; text-align: justify; text-indent: -8.55pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Atur posisi semi fowler atau fowler tinggi selama makan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.4pt; mso-list: l52 level1 lfo28; tab-stops: list 4.6pt 36.0pt; text-align: justify; text-indent: -8.55pt;">
<span lang="FI" style="font-family: Wingdings; mso-ansi-language: FI; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Kelola pemberan anti emetik:.....</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.4pt; mso-list: l52 level1 lfo28; tab-stops: list 4.6pt 36.0pt; text-align: justify; text-indent: -8.55pt;">
<span lang="FI" style="font-family: Wingdings; mso-ansi-language: FI; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Anjurkan banyak minum</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.4pt; mso-list: l52 level1 lfo28; tab-stops: list 4.6pt 36.0pt; text-align: justify; text-indent: -8.55pt;">
<span lang="FI" style="font-family: Wingdings; mso-ansi-language: FI; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Pertahankan terapi IV line</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.4pt; mso-list: l52 level1 lfo28; tab-stops: list 4.6pt 36.0pt; text-align: justify; text-indent: -8.55pt;">
<span lang="FI" style="font-family: Wingdings; mso-ansi-language: FI; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Catat adanya edema, hiperemik,
hipertonik papila lidah dan cavitas oval</span></div>
</td>
<td style="border: none; mso-cell-special: placeholder; padding: 0cm 0cm 0cm 0cm;" width="0"><div class="MsoNormal">
<br /></div>
</td>
</tr>
<tr style="height: 70.4pt; mso-row-margin-right: .3pt; mso-yfti-irow: 5;">
<td style="border-top: none; border: solid windowtext 1.0pt; height: 70.4pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 31.1pt;" valign="top" width="41">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">4</span></b></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 70.4pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 229.5pt;" valign="top" width="306">
<div class="MsoNormal" style="line-height: 150%;">
<b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV;">Intoleransi aktivitas </span></b></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="SV" style="mso-ansi-language: SV;">Berhubungan dengan :</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 22.85pt; mso-list: l89 level2 lfo29; tab-stops: list 72.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Tirah Baring atau imobilisasi</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 22.85pt; mso-list: l89 level2 lfo29; tab-stops: list 72.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Kelemahan menyeluruh</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 22.85pt; mso-list: l89 level2 lfo29; tab-stops: list 72.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Ketidakseimbangan antara
suplei oksigen dengan kebutuhan</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US">Gaya hidup yang
dipertahankan.</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US">DS:</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 22.55pt; mso-list: l93 level1 lfo34; text-align: justify; text-indent: -18.0pt;">
<span lang="FI" style="font-family: Symbol; mso-ansi-language: FI; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI;">Melaporkan
secara verbal adanya kelelahan atau kelemahan.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 22.55pt; mso-list: l93 level1 lfo34; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Symbol; mso-ansi-language: SV; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Adanya
dyspneu atau ketidaknyamanan saat beraktivitas.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.55pt; tab-stops: list 22.55pt;">
<span lang="EN-US">DO :</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.55pt; tab-stops: list 22.55pt;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 22.55pt; mso-list: l93 level1 lfo34; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Respon abnormal dari tekanan
darah atau nadi terhadap aktifitas</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 22.55pt; mso-list: l93 level1 lfo34; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Perubahan ECG : aritmia,
iskemia</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 70.4pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 238.3pt;" valign="top" width="318">
<div class="MsoNormal" style="line-height: 150%;">
<b><span lang="EN-US">NOC : </span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 19.15pt; mso-list: l12 level1 lfo30; tab-stops: list 19.15pt 81.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Self Care : ADLs</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 19.15pt; mso-list: l12 level1 lfo30; tab-stops: list 19.15pt 81.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Toleransi aktivitas</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 19.15pt; mso-list: l12 level1 lfo30; tab-stops: list 19.15pt 81.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Konservasi eneergi</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.15pt;">
<span lang="FI" style="mso-ansi-language: FI;">Setelah dilakukan tindakan keperawatan selama ….
</span><span lang="SV" style="mso-ansi-language: SV;">Pasien bertoleransi
terhadap aktivitas dengan <b>Kriteria Hasil :</b></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 19.15pt; mso-list: l41 level1 lfo31; tab-stops: list 19.15pt 81.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Berpartisipasi dalam aktivitas fisik
tanpa disertai peningkatan tekanan darah, nadi dan RR</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 19.15pt; mso-list: l41 level1 lfo31; tab-stops: list 19.15pt 81.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Mampu melakukan aktivitas sehari hari
(ADLs) secara mandiri</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 19.15pt; mso-list: l41 level1 lfo31; tab-stops: list 19.15pt 81.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Keseimbangan aktivitas dan istirahat</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
</td>
<td colspan="2" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 70.4pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 256.95pt;" valign="top" width="343">
<div class="MsoBodyTextIndent2" style="margin-left: 0cm;">
<b><span lang="EN-US">NIC :</span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US"></span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 10.65pt; mso-list: l79 level1 lfo32; tab-stops: list 10.65pt 36.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Observasi adanya pembatasan klien dalam
melakukan aktivitas</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 10.65pt; mso-list: l79 level1 lfo32; tab-stops: list 10.65pt 36.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Kaji adanya faktor yang menyebabkan
kelelahan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 10.65pt; mso-list: l79 level1 lfo32; tab-stops: list 10.65pt 36.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="NL" style="font-family: Wingdings; mso-ansi-language: NL; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="mso-ansi-language: NL;">Monitor nutrisi<span style="mso-spacerun: yes;"> </span>dan sumber energi yang adekuat</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 10.65pt; mso-list: l79 level1 lfo32; tab-stops: list 10.65pt 36.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="NL" style="font-family: Wingdings; mso-ansi-language: NL; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="mso-ansi-language: NL;">Monitor pasien akan adanya kelelahan
fisik dan emosi secara berlebihan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 10.65pt; mso-list: l79 level1 lfo32; tab-stops: list 10.65pt 36.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="NL" style="font-family: Wingdings; mso-ansi-language: NL; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="mso-ansi-language: NL;">Monitor respon kardivaskuler<span style="mso-spacerun: yes;"> </span>terhadap aktivitas (takikardi, disritmia,
sesak nafas, diaporesis, pucat, perubahan hemodinamik)</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 10.65pt; mso-list: l79 level1 lfo32; tab-stops: list 10.65pt 36.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="IT" style="font-family: Wingdings; mso-ansi-language: IT; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="IT" style="mso-ansi-language: IT;">Monitor pola tidur dan lamanya
tidur/istirahat pasien</span></div>
<div class="MsoBodyTextIndent2" style="margin-left: 10.65pt; mso-list: l7 level1 lfo33; tab-stops: list 10.65pt 18.0pt; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Kolaborasikan dengan Tenaga Rehabilitasi
Medik dalam merencanakan progran terapi yang tepat.</span></div>
<div class="MsoBodyTextIndent2" style="margin-left: 10.65pt; mso-list: l7 level1 lfo33; tab-stops: list 10.65pt 18.0pt; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Bantu klien untuk mengidentifikasi aktivitas yang mampu dilakukan</span></div>
<div class="MsoBodyTextIndent2" style="margin-left: 10.65pt; mso-list: l7 level1 lfo33; tab-stops: list 10.65pt 18.0pt; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Bantu untuk memilih aktivitas konsisten yang sesuai dengan
kemampuan fisik, psikologi dan sosial</span></div>
<div class="MsoBodyTextIndent2" style="margin-left: 10.65pt; mso-list: l7 level1 lfo33; tab-stops: list 10.65pt 18.0pt; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Bantu untuk mengidentifikasi dan mendapatkan sumber yang
diperlukan untuk aktivitas yang diinginkan</span></div>
<div class="MsoBodyTextIndent2" style="margin-left: 10.65pt; mso-list: l7 level1 lfo33; tab-stops: list 10.65pt 18.0pt; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Bantu untuk mendpatkan alat bantuan aktivitas seperti kursi roda,
krek</span></div>
<div class="MsoBodyTextIndent2" style="margin-left: 10.65pt; mso-list: l7 level1 lfo33; tab-stops: list 10.65pt 18.0pt; text-indent: -18.0pt;">
<span lang="FI" style="font-family: Wingdings; mso-ansi-language: FI; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Bantu untuk<span style="mso-spacerun: yes;"> </span>mengidentifikasi aktivitas yang disukai</span></div>
<div class="MsoBodyTextIndent2" style="margin-left: 10.65pt; mso-list: l7 level1 lfo33; tab-stops: list 10.65pt 18.0pt; text-indent: -18.0pt;">
<span lang="FI" style="font-family: Wingdings; mso-ansi-language: FI; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Bantu klien untuk membuat jadwal latihan
diwaktu luang</span></div>
<div class="MsoBodyTextIndent2" style="margin-left: 10.65pt; mso-list: l7 level1 lfo33; tab-stops: list 10.65pt 18.0pt; text-indent: -18.0pt;">
<span lang="FI" style="font-family: Wingdings; mso-ansi-language: FI; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Bantu pasien/keluarga untuk
mengidentifikasi kekurangan dalam beraktivitas</span></div>
<div class="MsoBodyTextIndent2" style="margin-left: 10.65pt; mso-list: l7 level1 lfo33; tab-stops: list 10.65pt 18.0pt; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Sediakan penguatan positif bagi yang
aktif beraktivitas</span></div>
<div class="MsoBodyTextIndent2" style="margin-left: 10.65pt; mso-list: l7 level1 lfo33; tab-stops: list 10.65pt 18.0pt; text-indent: -18.0pt;">
<span lang="NO-BOK" style="font-family: Wingdings; mso-ansi-language: NO-BOK; mso-bidi-font-family: Wingdings; mso-bidi-font-weight: normal; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="NO-BOK" style="mso-ansi-language: NO-BOK;">Bantu pasien untuk mengembangkan motivasi diri dan penguatan</span><b style="mso-bidi-font-weight: normal;"><span lang="NO-BOK" style="mso-ansi-language: NO-BOK;"></span></b></div>
<div class="MsoBodyTextIndent2" style="margin-left: 10.65pt; mso-list: l7 level1 lfo33; tab-stops: list 10.65pt 18.0pt; text-indent: -18.0pt;">
<span lang="IT" style="font-family: Wingdings; mso-ansi-language: IT; mso-bidi-font-family: Wingdings; mso-bidi-font-weight: normal; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="IT" style="mso-ansi-language: IT;">Monitor
respon fisik, emosi, sosial dan spiritual<b>.</b></span><b style="mso-bidi-font-weight: normal;"><span lang="IT" style="mso-ansi-language: IT;"></span></b></div>
</td>
<td style="border: none; mso-cell-special: placeholder; padding: 0cm 0cm 0cm 0cm;" width="0"><div class="MsoNormal">
<br /></div>
</td>
</tr>
<tr style="height: 170.75pt; mso-row-margin-right: .3pt; mso-yfti-irow: 6; mso-yfti-lastrow: yes;">
<td style="border-top: none; border: solid windowtext 1.0pt; height: 170.75pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 31.1pt;" valign="top" width="41">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">5</span></b></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 170.75pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 229.5pt;" valign="top" width="306">
<div class="MsoNormal" style="line-height: 150%;">
<b style="mso-bidi-font-weight: normal;"><span lang="FI" style="mso-ansi-language: FI;">Defisit perawatan diri</span></b></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="FI" style="mso-ansi-language: FI;">Berhubungan dengan : penurunan atau kurangnya motivasi, hambatan
lingkungan, kerusakan muskuloskeletal, kerusakan neuromuskular, nyeri,
kerusakan persepsi/ kognitif, kecemasan, kelemahan dan kelelahan.</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="FI" style="mso-ansi-language: FI;">DO :</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="FI" style="mso-ansi-language: FI;">ketidakmampuan untuk mandi, ketidakmampuan untuk berpakaian,
ketidakmampuan untuk makan, ketidakmampuan untuk toileting</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 170.75pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 238.3pt;" valign="top" width="318">
<div class="MsoNormal" style="line-height: 150%;">
<b><span lang="EN-US">NOC :</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 16.25pt; mso-list: l69 level1 lfo35; tab-stops: list 16.25pt 72.0pt; text-indent: -16.25pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Self care : Activity of Daily Living (ADLs)</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="FI" style="mso-ansi-language: FI; mso-bidi-font-weight: bold;">Setelah dilakukan tindakan keperawatan selama
…. Defisit perawatan diri teratas dengan kriteria hasil:</span><b><span lang="EN-US"></span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 16.25pt; mso-list: l69 level1 lfo35; tab-stops: list 16.25pt 72.0pt; text-indent: -16.25pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Klien terbebas dari bau badan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 16.25pt; mso-list: l69 level1 lfo35; tab-stops: list 16.25pt 72.0pt; text-indent: -16.25pt;">
<span lang="FI" style="font-family: Wingdings; mso-ansi-language: FI; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Menyatakan kenyamanan terhadap kemampuan
untuk melakukan ADLs</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 16.25pt; mso-list: l69 level1 lfo35; tab-stops: list 16.25pt 72.0pt; text-indent: -16.25pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Dapat melakukan ADLS dengan bantuan</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
</td>
<td colspan="2" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 170.75pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 256.95pt;" valign="top" width="343">
<div class="MsoNormal" style="line-height: 150%;">
<b><span lang="EN-US">NIC :</span></b></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US">S<b>elf Care
assistane : ADLs</b></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.65pt; mso-list: l33 level1 lfo36; tab-stops: list 21.65pt 36.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Monitor kemempuan klien untuk perawatan
diri yang mandiri.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.65pt; mso-list: l33 level1 lfo36; tab-stops: list 21.65pt 36.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Monitor kebutuhan klien untuk alat-alat bantu untuk kebersihan
diri, berpakaian, berhias, toileting dan makan.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.65pt; mso-list: l33 level1 lfo36; tab-stops: list 21.65pt 36.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Sediakan bantuan sampai klien mampu secara utuh untuk melakukan
self-care.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.65pt; mso-list: l33 level1 lfo36; tab-stops: list 21.65pt 36.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Dorong klien untuk melakukan aktivitas sehari-hari yang normal
sesuai kemampuan yang dimiliki.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.65pt; mso-list: l33 level1 lfo36; tab-stops: list 21.65pt 36.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Dorong untuk melakukan secara mandiri, tapi beri bantuan ketika
klien tidak mampu melakukannya.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.65pt; mso-list: l33 level1 lfo36; tab-stops: list 21.65pt 36.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Ajarkan klien/ keluarga untuk mendorong kemandirian, untuk
memberikan bantuan hanya jika pasien tidak mampu untuk melakukannya.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.65pt; mso-list: l33 level1 lfo36; tab-stops: list 21.65pt 36.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="FI" style="font-family: Wingdings; mso-ansi-language: FI; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Berikan aktivitas rutin sehari- hari
sesuai kemampuan.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.65pt; mso-list: l33 level1 lfo36; tab-stops: list 21.65pt 36.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Pertimbangkan usia klien jika mendorong pelaksanaan aktivitas
sehari-hari.<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
</td>
<td style="border: none; mso-cell-special: placeholder; padding: 0cm 0cm 0cm 0cm;" width="0"><div class="MsoNormal">
<br /></div>
</td>
</tr>
<tr height="0">
<td style="border: none;" width="41"><br /></td>
<td style="border: none;" width="306"><br /></td>
<td style="border: none;" width="318"><br /></td>
<td style="border: none;" width="341"><br /></td>
<td style="border: none;" width="2"><br /></td>
<td style="border: none;" width="0"><br /></td>
</tr>
</tbody></table>
</div>
<span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: SV; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;"><br clear="all" style="mso-break-type: section-break; page-break-before: auto;" />
</span>
<div class="WordSection5">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
</div>
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;"><br clear="all" style="mso-break-type: section-break; page-break-before: auto;" />
</span></b>
<div class="WordSection6">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">BAB III</span></b></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">TINJAUAN KASUS</span></b><b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;"></span></b></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-bottom: 10.0pt; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l95 level1 lfo105; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">A.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Identitas Pasien</span></b></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; tab-stops: 144.0pt; text-align: justify;">
<span lang="EN-US">Nama<span style="mso-tab-count: 1;"> </span>: Ny. H</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; tab-stops: 144.0pt; text-align: justify;">
<span lang="EN-US">Jenis
Kelamin <span style="mso-tab-count: 1;"> </span>: Perempuan</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; tab-stops: 144.0pt; text-align: justify;">
<span lang="EN-US">Umur
<span style="mso-tab-count: 1;"> </span>: 60 Tahun
</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; tab-stops: 144.0pt; text-align: justify;">
<span lang="EN-US">Alamat<span style="mso-tab-count: 1;"> </span>: Jl. KH A. Dahlan
no 76 Purworejo</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; tab-stops: 144.0pt; text-align: justify;">
<span lang="EN-US">Status
Perkawinan<span style="mso-tab-count: 1;"> </span>: Belum Kawin</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; tab-stops: 144.0pt; text-align: justify;">
<span lang="EN-US">Agama<span style="mso-tab-count: 1;"> </span>: Protestan</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; tab-stops: 144.0pt; text-align: justify;">
<span lang="EN-US">Pendidikan<span style="mso-tab-count: 1;"> </span>: -</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; tab-stops: 144.0pt; text-align: justify;">
<span lang="EN-US">Pekerjaan<span style="mso-tab-count: 1;"> </span>: Tidak Bekerja</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; tab-stops: 144.0pt; text-align: justify;">
<span lang="EN-US">Diagnosa
medis<span style="mso-tab-count: 1;"> </span>: Stoke Hemoragik</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; tab-stops: 144.0pt; text-align: justify;">
<span lang="EN-US">Tgl
Masuk RS<span style="mso-tab-count: 1;"> </span>: 23 Mei 2013</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; tab-stops: 144.0pt; text-align: justify;">
<span lang="EN-US">Tgl
Masuk ICU<span style="mso-tab-count: 1;"> </span>: 30 Mei 2013</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; tab-stops: 144.0pt; text-align: justify;">
<span lang="EN-US">Tanggal
Pengkajian<span style="mso-tab-count: 1;"> </span>: 30 Mei 2013</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; tab-stops: 144.0pt; text-align: justify;">
<span lang="EN-US">No.
RM<span style="mso-tab-count: 1;"> </span>: 190405</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; tab-stops: 144.0pt; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: 10.0pt; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l95 level1 lfo105; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">B.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Keluhan Utama</span></b></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; text-align: justify;">
<span lang="EN-US">Penurunan Kesadran,
tingkat kesadaran Sopor, GCS: E=2<span style="mso-spacerun: yes;"> </span>M=2<span style="mso-spacerun: yes;"> </span>V= 2</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: 10.0pt; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l95 level1 lfo105; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">C.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Riwayat Penyakit</span></b></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; text-align: justify;">
<span lang="EN-US">Keluarga pasien
mengatakan 8 hari yang lalu tiba tiba pasien tidak bisa bangun dan tidak bisa
berbicara.Kemudian keluarga langsung membawa pasien ke rumah sakit, 7 hari
pasien di rawat di bangsal tetapi tidak ada kemajuan sehingga di pindah ke ICU.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: 10.0pt; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l95 level1 lfo105; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">D.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Riwayat Penyakit Dahulu</span></b></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; text-align: justify;">
<span lang="EN-US">Menurut keluarga 7
bulan yang lalu<span style="mso-spacerun: yes;"> </span>pasien pernah dirawat
dirumah sakit ketika dilakukan pembedahan pada kaki kanannya akibat luka yang
ditimbulkan oleh penyakit Diabetes Melitus yang diderita Pasien.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: 10.0pt; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l95 level1 lfo105; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">E.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Riwayat Penyakit Keluarga</span></b></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; text-align: justify;">
<span lang="EN-US">Menurut keluarga
pasien, dalam keluarga tidak ada yang menderita stroke, akan tetapi keponakan
pasien menyebutkan bahwa ayah dari pasien menderita DM semasa hidupnya.</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l95 level1 lfo105; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">F.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Genogram</span></b></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
</div>
<table cellpadding="0" cellspacing="0" style="width: 100%px;">
<tbody>
<tr>
<td>
<div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US" style="font-size: 16.0pt;">X</span></div>
</div>
</td>
</tr>
</tbody></table>
<table cellpadding="0" cellspacing="0" style="width: 100%px;">
<tbody>
<tr>
<td>
<div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US" style="font-size: 16.0pt;">X</span></div>
</div>
</td>
</tr>
</tbody></table>
<table cellpadding="0" cellspacing="0" style="width: 100%px;">
<tbody>
<tr>
<td>
<div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US" style="font-size: 16.0pt;">X</span></div>
</div>
</td>
</tr>
</tbody></table>
<table cellpadding="0" cellspacing="0" style="width: 100%px;">
<tbody>
<tr>
<td>
<div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US" style="font-size: 16.0pt;">X</span></div>
</div>
</td>
</tr>
</tbody></table>
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US"> </span></b>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; tab-stops: 148.55pt; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; tab-stops: 148.55pt; text-align: justify;">
<br /></div>
<br clear="ALL" style="mso-ignore: vglayout;" />
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; tab-stops: 148.55pt; text-align: justify;">
</div>
<table cellpadding="0" cellspacing="0" style="width: 100%px;">
<tbody>
<tr>
<td>
<div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US" style="font-size: 16.0pt;">X</span></div>
</div>
</td>
</tr>
</tbody></table>
<table cellpadding="0" cellspacing="0" style="width: 100%px;">
<tbody>
<tr>
<td>
<div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US" style="font-size: 16.0pt;">X</span></div>
</div>
</td>
</tr>
</tbody></table>
<table cellpadding="0" cellspacing="0" style="width: 100%px;">
<tbody>
<tr>
<td>
<div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US" style="font-size: 16.0pt;">X</span></div>
</div>
</td>
</tr>
</tbody></table>
<span lang="EN-US"><span style="mso-tab-count: 1;"> </span></span>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; text-align: justify;">
</div>
<table cellpadding="0" cellspacing="0" style="width: 100%px;">
<tbody>
<tr>
<td>
<div>
<div class="MsoNormal">
<span lang="EN-US">X</span></div>
</div>
</td>
</tr>
</tbody></table>
<table cellpadding="0" cellspacing="0" style="width: 100%px;">
<tbody>
<tr>
<td>
<div>
<div class="MsoNormal">
<span lang="EN-US" style="font-size: 11.0pt;">X</span></div>
</div>
</td>
</tr>
</tbody></table>
<table cellpadding="0" cellspacing="0" style="width: 100%px;">
<tbody>
<tr>
<td>
<div>
<div class="MsoNormal">
<span lang="EN-US">X</span></div>
</div>
</td>
</tr>
</tbody></table>
<table cellpadding="0" cellspacing="0" style="width: 100%px;">
<tbody>
<tr>
<td>
<div>
<div class="MsoNormal">
<span style="mso-ansi-language: IN; mso-fareast-language: IN; mso-no-proof: yes;">
</span><span lang="EN-US">X</span></div>
</div>
</td>
</tr>
</tbody></table>
<table cellpadding="0" cellspacing="0" style="width: 100%px;">
<tbody>
<tr>
<td>
<div>
<div class="MsoNormal">
<span lang="EN-US">X</span></div>
</div>
</td>
</tr>
</tbody></table>
<table cellpadding="0" cellspacing="0" style="width: 100%px;">
<tbody>
<tr>
<td>
<div>
<div class="MsoNormal">
<span lang="EN-US">X</span></div>
</div>
</td>
</tr>
</tbody></table>
<table cellpadding="0" cellspacing="0" style="width: 100%px;">
<tbody>
<tr>
<td>
<div>
<div class="MsoNormal">
<span lang="EN-US">X</span></div>
</div>
</td>
</tr>
</tbody></table>
<table cellpadding="0" cellspacing="0" style="width: 100%px;">
<tbody>
<tr>
<td>
<div>
<div class="MsoNormal">
<span lang="EN-US">X</span></div>
</div>
</td>
</tr>
</tbody></table>
<table cellpadding="0" cellspacing="0" style="width: 100%px;">
<tbody>
<tr>
<td>
<div>
<div class="MsoNormal">
<span lang="EN-US">X</span></div>
</div>
</td>
</tr>
</tbody></table>
<table cellpadding="0" cellspacing="0" style="width: 100%px;">
<tbody>
<tr>
<td>
<div>
<div class="MsoNormal">
<span style="mso-ansi-language: IN; mso-fareast-language: IN; mso-no-proof: yes;">
</span><span lang="EN-US">X</span></div>
</div>
</td>
</tr>
</tbody></table>
<table cellpadding="0" cellspacing="0" style="width: 100%px;">
<tbody>
<tr>
<td>
<div>
<div class="MsoNormal">
<span lang="EN-US" style="font-size: 11.0pt;">X</span></div>
</div>
</td>
</tr>
</tbody></table>
<table cellpadding="0" cellspacing="0" style="width: 100%px;">
<tbody>
<tr>
<td>
<div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US" style="font-size: 16.0pt;">X</span></div>
</div>
</td>
</tr>
</tbody></table>
<span lang="EN-US"> </span>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<br clear="ALL" style="mso-ignore: vglayout;" />
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; text-align: justify;">
<span lang="EN-US">Keterangan:</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; tab-stops: 108.0pt; text-align: justify;">
<span lang="EN-US"><span style="mso-tab-count: 1;"> </span>:
Laki-laki</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; tab-stops: 108.0pt; text-align: justify;">
<span lang="EN-US"><span style="mso-tab-count: 1;"> </span>:
Perempuan</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; tab-stops: 108.0pt; text-align: justify;">
<span lang="EN-US"><span style="mso-tab-count: 1;"> </span>:
Pasien</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; tab-stops: 108.0pt; text-align: justify;">
<span lang="EN-US"><span style="mso-tab-count: 1;"> </span>:
Dalam satu rumah</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; tab-stops: 108.0pt; text-align: justify;">
<span lang="EN-US"><span style="mso-spacerun: yes;"> </span>X<span style="mso-tab-count: 1;"> </span>:
Meninggal</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; text-align: justify;">
<span lang="EN-US">Kedua orang tua
pasien telah meninggal, pasien hidup sendiri, dia dirumah bersama seorang yang
mengurusinya. Sedangkan orang orang terdekat adalah, keponakannya,akan tetapi
mereka sudah berkeluarga dan tinggal di luar kota unt</span><span style="mso-ansi-language: IN;">u</span><span lang="EN-US">k mengurus usahanya.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.0pt; mso-add-space: auto; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: 10.0pt; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l95 level1 lfo105; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">G.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Primary Suvey</span></b></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: 10.0pt; mso-add-space: auto; mso-list: l23 level1 lfo106; text-align: justify; text-indent: -18.0pt;">
<i style="mso-bidi-font-style: normal;"><span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></i><i style="mso-bidi-font-style: normal;"><span lang="EN-US">Airway</span></i></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Tidak ada sumbatan jalan nafas berupa cairan, sputum atau benda
asing.</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: 10.0pt; mso-add-space: auto; mso-list: l23 level1 lfo106; text-align: justify; text-indent: -18.0pt;">
<i style="mso-bidi-font-style: normal;"><span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></i><i style="mso-bidi-font-style: normal;"><span lang="EN-US">Breathing</span></i></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Respiratory rate </span><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 1;"> </span></span><span lang="EN-US">: 24</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">SPO2 </span><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 3;"> </span></span><span lang="EN-US">: 99%</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Suara nafas </span><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 2;"> </span></span><span lang="EN-US">:
vesikuler</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Irama nafas regular, tidak terdapat batuk, tidak ada retraksi
dinding dada, tidak menggunakan pernafasan cuping hidung</span><span style="mso-ansi-language: IN;">.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: 10.0pt; mso-add-space: auto; mso-list: l23 level1 lfo106; text-align: justify; text-indent: -18.0pt;">
<i style="mso-bidi-font-style: normal;"><span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></i><i style="mso-bidi-font-style: normal;"><span lang="EN-US">Circulation</span></i></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; tab-stops: 108.0pt; text-align: justify;">
<span lang="EN-US">Suhu <span style="mso-tab-count: 1;"> </span>:
37,1 °C</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; tab-stops: 108.0pt; text-align: justify;">
<span lang="EN-US">TD<span style="mso-tab-count: 1;"> </span>:
201/133 mmHg</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; tab-stops: 108.0pt; text-align: justify;">
<span lang="EN-US">MAP<span style="mso-tab-count: 1;"> </span>:
137</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; tab-stops: 108.0pt; text-align: justify;">
<span lang="EN-US">HR<span style="mso-tab-count: 1;"> </span>:
64 x/menit</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; tab-stops: 108.0pt; text-align: justify;">
<span lang="EN-US">Turgor kulit<span style="mso-tab-count: 1;"> </span>: Buruk</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; tab-stops: 108.0pt; text-align: justify;">
<span lang="EN-US">Mata<span style="mso-tab-count: 1;"> </span>:
Tidak cekung</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Capilary refill :< 2 detik</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Tidak sianosis, anemis, akral hangat, tidak ada muntah</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: 10.0pt; mso-add-space: auto; mso-list: l23 level1 lfo106; text-align: justify; text-indent: -18.0pt;">
<i style="mso-bidi-font-style: normal;"><span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></i><i style="mso-bidi-font-style: normal;"><span lang="EN-US">Disability</span></i></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Tingkat kesadaran : Sopor</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">GCS:</span><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 3;"> </span></span><span lang="EN-US">E=2</span><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 1;"> </span></span><span lang="EN-US">M=2</span><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 1;"> </span></span><span lang="EN-US">V=2</span></div>
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<span lang="EN-US">Pupil :</span><span style="mso-ansi-language: IN;">I</span><span lang="EN-US">sokor</span></div>
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<i style="mso-bidi-font-style: normal;"><span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></i><i style="mso-bidi-font-style: normal;"><span lang="EN-US">Eksposure</span></i></div>
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<span lang="EN-US">Terdapat luka lecet pada paha kanan, tangan kanan dan kiri serta
terdapat luka bekas debridement 7 bula</span><span style="mso-ansi-language: IN;">n</span><span lang="EN-US"> yang lalu pada kaki kanannya.</span></div>
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<i style="mso-bidi-font-style: normal;"><span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></i><i style="mso-bidi-font-style: normal;"><span lang="EN-US">Fluid</span></i></div>
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<span lang="EN-US">Klien terpasang kateter no. 16 dengan jumlah urine 300 cc berwarna
kuning jernih</span><span style="mso-ansi-language: IN;"></span></div>
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<i style="mso-bidi-font-style: normal;"><span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">7.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></i><i style="mso-bidi-font-style: normal;"><span lang="EN-US">Gastric</span></i></div>
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<span lang="EN-US">Klien terpasang NGT, cairan residu berwarna kuning.</span><span style="mso-ansi-language: IN;"></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">H.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Pemeriksaan Fisik</span></b></div>
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<span lang="EN-US">Keadaan
Umum<span style="mso-tab-count: 1;"> </span>: Klien </span><span style="mso-ansi-language: IN;">t</span><span lang="EN-US">ampak lemah</span></div>
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<span lang="EN-US">Tingkat
Kesadaran <span style="mso-tab-count: 1;"> </span>: Sopor</span></div>
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<span lang="EN-US">GCS<span style="mso-tab-count: 1;"> </span>: E=2 </span><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 1;"> </span></span><span lang="EN-US">M=2</span><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 1;"> </span></span><span lang="EN-US">V=2</span></div>
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<span lang="EN-US">BB/TB<span style="mso-tab-count: 1;"> </span>: 95 Kg/ 157 cm</span></div>
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<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Kepala</span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Inspeksi</span></b><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 1;"> </span>: </span><span lang="EN-US">Bentuk kepala bulat, tidak ada lesi dikepala, rambur berwarna putih,
lurus, distribusi merata.</span><span style="mso-ansi-language: IN;"></span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Palpasi <span style="mso-tab-count: 1;"> </span></span></b><span style="mso-ansi-language: IN;">: Tidak terdapat oedema</span></div>
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<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Mata</span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Inspeksi</span></b><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 1;"> </span>: </span><span lang="EN-US">Kedua mata klien simetris, konjungtiva tidak anemis, pupil isokor,
diameter kanan kiri 2mm/2mm, reaksi cahaya +/+.</span><span style="mso-ansi-language: IN;"></span></div>
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<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Telinga</span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Inspeksi</span></b><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 1;"> </span>: </span><span lang="EN-US">Kedua telinga simetris lengkap dan terdapat kedua lubang telinga,
tidak ada lesi, terdapat serumen, tidak terdapat pengeluaran darah atau cairan.</span></div>
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<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Hidung</span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Inspeksi</span></b><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 1;"> </span>: </span><span lang="EN-US">Posisi septum nasal simetris, tidak terdapat pernafasan cuping
hidung, tidak terdapat pengeluarean lender atau darah, terpasangoksigen 3 liter
permenit dengan nasal kanul dan terpasang NGT pada salah satu lubang hidung.</span></div>
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<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Mulut dan tenggorokan</span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Inspeksi</span></b><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 1;"> </span>: </span><span lang="EN-US">Mukosa bibir lembab, gigi klien tidak lengkap, mulut kotor.</span></div>
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<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Leher</span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Inspeksi</span></b><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 1;"> </span>: Leher
Simetris, t</span><span lang="EN-US">idak terdapat jejas di leher</span><span style="mso-ansi-language: IN;"></span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Palpasi</span></b><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 2;"> </span>:
T</span><span lang="EN-US">idak terdapat pembengkakan, tidak terdapat pembesaran
kelenjaran limfe, dan tidak ada pembesaran kelenjar tiroid.</span></div>
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<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">7.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Thorak</span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Inspeksi</span></b><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 1;"> </span>:
</span><span lang="EN-US">Thoraks simetris, klien tidak menggunakan otot bantu
nafas dan tidak terdapat retraksi dinding dada</span><span style="mso-ansi-language: IN;">, </span><i style="mso-bidi-font-style: normal;"><span lang="EN-US">Respiratory
Rate</span></i><span lang="EN-US"> 2</span><span style="mso-ansi-language: IN;">4</span><span lang="EN-US">x/menit.</span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Palpasi</span></b><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 1;"> </span>:
</span><span lang="EN-US">Gerakan paru saat inspirasi dan ekapirasi sama, tidak
terdapat massa, tidak terdapat fraktur pada daerah thorak</span><span style="mso-ansi-language: IN;">, </span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Perkusi</span></b><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 1;"> </span>:
Perkusi paru resonan</span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Auskultasi</span></b><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 1;"> </span>:
</span><span lang="EN-US">Tidak terdapat suara tambahan</span><span style="mso-ansi-language: IN;">, </span><span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">bunyi na</span><span lang="EN-US" style="mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">f</span><span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">as vesikuler</span><span style="mso-ansi-language: IN;"></span></div>
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<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">8.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Jantung</span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Inspeksi</span></b><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 1;"> </span>:
</span><span lang="EN-US">Tidak terdapat palpitasi, ictus cordis tidak terlihat.</span><span style="mso-ansi-language: IN;"></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Palpasi</span></b><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 1;"> </span>:
</span><span lang="EN-US">Heart Rate 6</span><span style="mso-ansi-language: IN;">4</span><span lang="EN-US"> x/menit, <i style="mso-bidi-font-style: normal;">capillary refil</i>l
selama 2 detik</span><span style="mso-ansi-language: IN;"></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Perkusi </span></b><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 1;"> </span>:
</span><span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";">Perkusi
jantung terdengar pekak.</span><span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";"></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Auskultasi</span></b><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 1;"> </span>:
</span><span lang="EN-US">Tekanan darah 201/133 mmHg mmHg, bunyi jantung S1 dan
S2 dengan irama reguler, tidak terdapat bunyi jantung tambahan murmur, gallop.</span></div>
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<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">9.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Payudara</span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Inspeksi</span></b><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 1;"> </span>: </span><span lang="EN-US">Payudara simetris, letak putting susu tepat di tengah aerola, </span><b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Palpasi</span></b><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 1;"> </span>: T</span><span lang="EN-US">idak terdapat benjolan di sekitar payudara.</span><span style="mso-ansi-language: IN;"></span></div>
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<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">10.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Abdomen</span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Inspeksi</span></b><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 1;"> </span>: </span><span lang="EN-US">Perut Nampak besar ( banyak penumpukan lemak), kulit elastis, tidak
terdapat lesi atau massa</span><span style="mso-ansi-language: IN;"></span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Palpasi</span></b><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 1;"> </span>: Tidak
terdapat Asites</span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Perkusi</span></b><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 1;"> </span>:
T</span><span lang="EN-US">impani</span><span style="mso-ansi-language: IN;"></span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Auskultasi</span></b><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 1;"> </span>: B</span><span lang="EN-US">ising usus 8x</span><span style="mso-ansi-language: IN;">/</span><span lang="EN-US">menit, </span></div>
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<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">11.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Genetalia dan perineal</span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Inspeksi</span></b><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 1;"> </span>: </span><span lang="EN-US">Terpasang selang kateter denga urin kuning jernih</span></div>
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<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">12.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Ekstermitas</span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Inspeksi</span></b><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 1;"> </span>:</span></div>
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<span lang="EN-US">Pada Ekstermitas atas kanan<span style="mso-tab-count: 1;"> </span>: Terdapat pembengkakan dan
terpasang IVFD </span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; tab-stops: 144.0pt 216.0pt; text-align: justify;">
<span lang="EN-US">Pada ekstermitas Atas Kiri <span style="mso-tab-count: 1;"> </span>: Nampak sedikit bengkak</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 225.0pt; mso-add-space: auto; tab-stops: 144.0pt 216.0pt; text-align: justify; text-indent: -189.0pt;">
<span lang="EN-US">Pada ekstermitas kanan bawah<span style="mso-tab-count: 1;"> </span>:
terdapat luka bekas debridement ulkus DM, bagian paha terdapat penggelapan
warna kulit akibat bedtres yang lama. Terdapat udema</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 225.0pt; mso-add-space: auto; tab-stops: 144.0pt 216.0pt; text-align: justify; text-indent: -189.0pt;">
<span lang="EN-US">Pada ekstermitas kiri bawah <span style="mso-tab-count: 1;"> </span>:
terdapat penggelapan warna kulit akibat bedtres yang lama. Terdapat udema</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; tab-stops: 144.0pt 216.0pt; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: 10.0pt; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l95 level1 lfo105; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">I.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pengkajian Pola system</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: 10.0pt; mso-add-space: auto; mso-list: l49 level1 lfo108; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pola persepsi dan Managemen
Terhadap Kesehatan</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Klien saat ini di rawat di ruang ICU, klien mengalami penurunan
kesadaran dan tampak lemah.Keluarga berharap klien cepat sembuh dan bisa
kembali kerumah.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: 10.0pt; mso-add-space: auto; mso-list: l49 level1 lfo108; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pola Nutrisi dan metabolic
(Diit Dan Pemasukan Makanan)</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Keluarga klien mengatakan saat </span><span style="mso-ansi-language: IN;">dirumah</span><span lang="EN-US">,</span><span style="mso-ansi-language: IN;">klien
biasa makan </span><span lang="EN-US">2</span><span style="mso-ansi-language: IN;">x/hari dengan</span><span lang="EN-US"> nasi,</span><span style="mso-ansi-language: IN;"> lauk pauk dan sayuran,</span><span lang="EN-US"> pada pagi hari klien makan roti
atau kue dan minum t</span><span style="mso-ansi-language: IN;">eh</span><span lang="EN-US">.Klien m</span><span style="mso-ansi-language: IN;">inum 5-6 gelas </span><span lang="EN-US">perhari</span><span style="mso-ansi-language: IN;">. S</span><span lang="EN-US">aat</span><span style="mso-ansi-language: IN;"> dirumah sakit</span><span lang="EN-US">,klien terpasang NGT,</span><span style="mso-ansi-language: IN;"><span style="mso-spacerun: yes;"> </span>klien makan makanan yang disediakan rumah
sakit yaitu </span><span lang="EN-US">peptisol/ diabetasol</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: 10.0pt; mso-add-space: auto; mso-list: l49 level1 lfo108; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pola Eliminasi</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Sebelum sakit, keluarga </span><span style="mso-ansi-language: IN;"><span style="mso-spacerun: yes;"> </span>klien</span><span lang="EN-US"> mengatakan bahwa
klien biasa BAB 1 kali sehari atau 2 hari sekali</span><span style="mso-ansi-language: IN;">. </span><span lang="EN-US">Saat di rumah sakit, klien BAB 1x.Klien terpasang
kateter dengan urine berwarna kuning jernih.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: 10.0pt; mso-add-space: auto; mso-list: l49 level1 lfo108; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pola Aktivitas </span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Keluarga klien mengatakan, sebelum masuk rumahsakitklien
beraktivitas minimal, klien tidak dapat berjalan karena mengalami kelemahan
pada tangan dan kaki sebe</span><span style="mso-ansi-language: IN;">l</span><span lang="EN-US">ah kanan.Aktivitas klien sehari-hari dibantu oleh keluarga
klien.Selama dirawat di rumah sakit untuk memenuhi <i style="mso-bidi-font-style: normal;">activity daily living</i> dibantu oleh perawat dan keluarga.</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: 10.0pt; mso-add-space: auto; mso-list: l49 level1 lfo108; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pola Istirahat : Tidur</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Sebelum sakit keluarga</span><span style="mso-ansi-language: IN;">
klien</span><span lang="EN-US"> mengatakan bahwa klien biasa tidur </span><span style="mso-ansi-language: IN;">pukul 21.00 - 05.00.</span><span lang="EN-US">Klien
biasa tidur siang.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: 10.0pt; mso-add-space: auto; mso-list: l49 level1 lfo108; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pola Peran Hubungan</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Keluarga klien mengatakan, klien mempunyai hubungan yang baik dengan
keluarga, </span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: 10.0pt; mso-add-space: auto; mso-list: l49 level1 lfo108; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">7.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pola seksual dan reproduksi</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Keluarga k</span><span style="mso-ansi-language: IN;">lien mengatakan</span><span lang="EN-US"> klien tidak memiliki keluhan di organ reproduksinya.Pasien belum
pernah memiliki suami maupun anak.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: 10.0pt; mso-add-space: auto; mso-list: l49 level1 lfo108; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">8.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pola koping dan toleransi
terhadap stress</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Keluarga klien mengatakan klien dapat menerima keadaannya yang
sekarang, dan dapat mengontrol emosinya.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: 10.0pt; mso-add-space: auto; mso-list: l49 level1 lfo108; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">9.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pola nilai kepercayaan</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Keluarga klien</span><span style="mso-ansi-language: IN;"> mengatakan
agama yang dianut keluarga dan klien adalah </span><span lang="EN-US">protestan</span><span style="mso-ansi-language: IN;">. </span><span lang="EN-US">Sewaktu masih sehat
pasien rajin melaksanakan ibadah di gereja.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 42.55pt; mso-add-space: auto; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 35.45pt; mso-add-space: auto; mso-list: l65 level1 lfo37; text-indent: -21.25pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">J.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">DATA PENUNJANG</span><span lang="EN-US"></span></b></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 2.0cm; mso-add-space: auto; mso-list: l24 level1 lfo40; text-indent: -21.25pt;">
<span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pemeriksaan </span><span style="mso-ansi-language: IN;">Laboratorium </span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 2.0cm; mso-add-space: auto;">
<span lang="EN-US">23 Mei 2013</span><span style="mso-ansi-language: IN;"></span></div>
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: none; margin-left: 62.1pt; mso-border-alt: solid windowtext .5pt; mso-border-insideh: .5pt solid windowtext; mso-border-insidev: .5pt solid windowtext; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-yfti-tbllook: 1184;">
<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td style="border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Pemeriksaan</span></b></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 3.0cm;" valign="top" width="113">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Hasil</span></b></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 78.0pt;" valign="top" width="104">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Satuan</span></b></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 92.1pt;" valign="top" width="123">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Nilai normal</span></b></div>
</td>
</tr>
<tr style="mso-yfti-irow: 1;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span style="mso-ansi-language: IN;">Glukosa sewaktu</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 3.0cm;" valign="top" width="113">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">138</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 78.0pt;" valign="top" width="104">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span style="mso-ansi-language: IN;">mg/dl</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 92.1pt;" valign="top" width="123">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span style="mso-ansi-language: IN;">70-140</span></div>
</td>
</tr>
<tr style="height: 10.0pt; mso-yfti-irow: 2;">
<td style="border-top: none; border: solid windowtext 1.0pt; height: 10.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span style="mso-ansi-language: IN;">Urea </span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 10.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 3.0cm;" valign="top" width="113">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">17</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 10.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 78.0pt;" valign="top" width="104">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span style="mso-ansi-language: IN;">mg/dl</span><span lang="EN-US"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 10.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 92.1pt;" valign="top" width="123">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span style="mso-ansi-language: IN;">10-50</span></div>
</td>
</tr>
<tr style="height: 9.95pt; mso-yfti-irow: 3;">
<td style="border-top: none; border: solid windowtext 1.0pt; height: 9.95pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span style="mso-ansi-language: IN;">Kreatinin </span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 9.95pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 3.0cm;" valign="top" width="113">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">1,08</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 9.95pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 78.0pt;" valign="top" width="104">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span style="mso-ansi-language: IN;">mg/dl</span><span lang="EN-US"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 9.95pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 92.1pt;" valign="top" width="123">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span style="mso-ansi-language: IN;">0,5-1,2</span></div>
</td>
</tr>
<tr style="height: 9.95pt; mso-yfti-irow: 4;">
<td style="border-top: none; border: solid windowtext 1.0pt; height: 9.95pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span style="mso-ansi-language: IN;">C</span><span lang="EN-US">h</span><span style="mso-ansi-language: IN;">olesterol </span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 9.95pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 3.0cm;" valign="top" width="113">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">293</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 9.95pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 78.0pt;" valign="top" width="104">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span style="mso-ansi-language: IN;">mg/dl</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 9.95pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 92.1pt;" valign="top" width="123">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span style="mso-ansi-language: IN;">50-250</span></div>
</td>
</tr>
<tr style="height: 9.95pt; mso-yfti-irow: 5;">
<td style="border-top: none; border: solid windowtext 1.0pt; height: 9.95pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">HDL Cholesterol</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 9.95pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 3.0cm;" valign="top" width="113">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">58</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 9.95pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 78.0pt;" valign="top" width="104">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">mg/dl</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 9.95pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 92.1pt;" valign="top" width="123">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">0-55</span></div>
</td>
</tr>
<tr style="height: 9.95pt; mso-yfti-irow: 6;">
<td style="border-top: none; border: solid windowtext 1.0pt; height: 9.95pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">LDL Cholesterol</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 9.95pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 3.0cm;" valign="top" width="113">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">395</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 9.95pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 78.0pt;" valign="top" width="104">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">mg/dl</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 9.95pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 92.1pt;" valign="top" width="123">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">0-150</span></div>
</td>
</tr>
<tr style="height: 9.95pt; mso-yfti-irow: 7;">
<td style="border-top: none; border: solid windowtext 1.0pt; height: 9.95pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span style="mso-ansi-language: IN;">Trigliserida </span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 9.95pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 3.0cm;" valign="top" width="113">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">129</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 9.95pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 78.0pt;" valign="top" width="104">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span style="mso-ansi-language: IN;">mg/dl</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 9.95pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 92.1pt;" valign="top" width="123">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span style="mso-ansi-language: IN;">0-150</span></div>
</td>
</tr>
<tr style="height: 10.0pt; mso-yfti-irow: 8;">
<td style="border-top: none; border: solid windowtext 1.0pt; height: 10.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span style="mso-ansi-language: IN;">SGOT</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 10.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 3.0cm;" valign="top" width="113">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">19</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 10.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 78.0pt;" valign="top" width="104">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span style="mso-ansi-language: IN;">u/L</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 10.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 92.1pt;" valign="top" width="123">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span style="mso-ansi-language: IN;">0-37</span></div>
</td>
</tr>
<tr style="height: 9.2pt; mso-yfti-irow: 9;">
<td style="border-top: none; border: solid windowtext 1.0pt; height: 9.2pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span style="mso-ansi-language: IN;">SGPT</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 9.2pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 3.0cm;" valign="top" width="113">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">10</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 9.2pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 78.0pt;" valign="top" width="104">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span style="mso-ansi-language: IN;">u/L</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 9.2pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 92.1pt;" valign="top" width="123">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span style="mso-ansi-language: IN;">0-42</span></div>
</td>
</tr>
<tr style="height: 9.2pt; mso-yfti-irow: 10;">
<td style="border-top: none; border: solid windowtext 1.0pt; height: 9.2pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span style="mso-ansi-language: IN;">Asam urat</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 9.2pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 3.0cm;" valign="top" width="113">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">5,0</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 9.2pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 78.0pt;" valign="top" width="104">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span style="mso-ansi-language: IN;">mg/dl</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 9.2pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 92.1pt;" valign="top" width="123">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span style="mso-ansi-language: IN;">3,4-7</span></div>
</td>
</tr>
<tr style="height: 12.25pt; mso-yfti-irow: 11;">
<td style="border-top: none; border: solid windowtext 1.0pt; height: 12.25pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span style="mso-ansi-language: IN;">K</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 12.25pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 3.0cm;" valign="top" width="113">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">3,3</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 12.25pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 78.0pt;" valign="top" width="104">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">m</span><span style="mso-ansi-language: IN;">mol/L</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 12.25pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 92.1pt;" valign="top" width="123">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span style="mso-ansi-language: IN;">3,4-5,4</span></div>
</td>
</tr>
<tr style="height: 9.95pt; mso-yfti-irow: 12;">
<td style="border-top: none; border: solid windowtext 1.0pt; height: 9.95pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span style="mso-ansi-language: IN;">Na</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 9.95pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 3.0cm;" valign="top" width="113">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">145</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 9.95pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 78.0pt;" valign="top" width="104">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">m</span><span style="mso-ansi-language: IN;">mol/L</span><span lang="EN-US"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 9.95pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 92.1pt;" valign="top" width="123">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span style="mso-ansi-language: IN;">135-155</span></div>
</td>
</tr>
<tr style="height: 10.0pt; mso-yfti-irow: 13;">
<td style="border-top: none; border: solid windowtext 1.0pt; height: 10.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span style="mso-ansi-language: IN;">Cl</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 10.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 3.0cm;" valign="top" width="113">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">113</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 10.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 78.0pt;" valign="top" width="104">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">m</span><span style="mso-ansi-language: IN;">mol/L</span><span lang="EN-US"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 10.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 92.1pt;" valign="top" width="123">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span style="mso-ansi-language: IN;">95-108</span></div>
</td>
</tr>
<tr style="height: 11.5pt; mso-yfti-irow: 14; mso-yfti-lastrow: yes;">
<td style="border-top: none; border: solid windowtext 1.0pt; height: 11.5pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span style="mso-ansi-language: IN;">HbsAg</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 11.5pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 3.0cm;" valign="top" width="113">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">-</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 11.5pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 78.0pt;" valign="top" width="104">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 11.5pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 92.1pt;" valign="top" width="123">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">Negatif</span></div>
</td>
</tr>
</tbody></table>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US"><span style="mso-tab-count: 2;"> </span></span></div>
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: none; margin-left: 62.1pt; mso-border-alt: solid windowtext .5pt; mso-border-insideh: .5pt solid windowtext; mso-border-insidev: .5pt solid windowtext; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-yfti-tbllook: 1184;">
<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0; mso-yfti-lastrow: yes;">
<td style="border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Pemeriksaan</span></b></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 3.0cm;" valign="top" width="113">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Hasil</span></b></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 78.0pt;" valign="top" width="104">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Satuan</span></b></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 92.1pt;" valign="top" width="123">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Nilai normal</span></b></div>
</td>
</tr>
</tbody></table>
<table border="1" cellpadding="0" cellspacing="0" class="MsoTableGrid" style="border-collapse: collapse; border: none; margin-left: 62.1pt; mso-border-alt: solid windowtext .5pt; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-yfti-tbllook: 1184;">
<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td style="border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">WBC</span></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 3.0cm;" valign="top" width="113">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">7,36</span></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 78.0pt;" valign="top" width="104">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">10<sup>3</sup>/UL</span></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 92.1pt;" valign="top" width="123">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">4,8-10,8
</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 1;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">RBC</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 3.0cm;" valign="top" width="113">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">4,47</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 78.0pt;" valign="top" width="104">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">10<sup>6
/</sup>UL</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 92.1pt;" valign="top" width="123">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">P :
4,7 – 6,1 </span></div>
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">W :
4,2-5,4 </span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 2;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">HGB</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 3.0cm;" valign="top" width="113">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">12,0</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 78.0pt;" valign="top" width="104">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">gr/dl</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 92.1pt;" valign="top" width="123">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">P :
14-18 gr/dl</span></div>
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">W :
12-16 gr/dl</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 3;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">HCT</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 3.0cm;" valign="top" width="113">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">7,0</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 78.0pt;" valign="top" width="104">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">%</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 92.1pt;" valign="top" width="123">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">P :
42-52 %</span></div>
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">W :
37-47%</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 4; mso-yfti-lastrow: yes;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">PLT</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 3.0cm;" valign="top" width="113">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">356</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 78.0pt;" valign="top" width="104">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">10<sup>3</sup>/UL</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 92.1pt;" valign="top" width="123">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">150-400</span></div>
</td>
</tr>
</tbody></table>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 2.0cm; mso-add-space: auto;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 2.0cm; mso-add-space: auto;">
<span lang="EN-US">Pemeriksaan Urinalisa 23 <span style="mso-spacerun: yes;"> </span>Mei 2013<span style="mso-tab-count: 1;"> </span></span></div>
<table border="1" cellpadding="0" cellspacing="0" class="MsoTableGrid" style="border-collapse: collapse; border: none; margin-left: 62.1pt; mso-border-alt: solid windowtext .5pt; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-yfti-tbllook: 1184;">
<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td style="border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Pemeriksaan</span></b></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.35pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Hasil</span></b></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 151.9pt;" valign="top" width="203">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Nilai Normal</span></b></div>
</td>
</tr>
<tr style="mso-yfti-irow: 1;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Warna</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.35pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">Kuning
</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 151.9pt;" valign="top" width="203">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">Kuning
Muda-Kuning</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 2;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Kejernihan</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.35pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">Jernih</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 151.9pt;" valign="top" width="203">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">Jernih</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 3;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Berat Jenis</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.35pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">1017</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 151.9pt;" valign="top" width="203">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">1015-1030</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 4;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">pH</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.35pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">5,5</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 151.9pt;" valign="top" width="203">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">4,0-7,8</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 5;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Leukosit</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.35pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">2+</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 151.9pt;" valign="top" width="203">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">-</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 6;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Nitrit</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.35pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">-</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 151.9pt;" valign="top" width="203">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">-</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 7;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Protein</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.35pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">3+</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 151.9pt;" valign="top" width="203">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">-</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 8;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Glukosa</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.35pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">-</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 151.9pt;" valign="top" width="203">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">-</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 9;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Keton</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.35pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">-</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 151.9pt;" valign="top" width="203">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">-</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 10;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Urobilinogen</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.35pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">-</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 151.9pt;" valign="top" width="203">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">-</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 11;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Eritrosit</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.35pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">3+</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 151.9pt;" valign="top" width="203">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">-</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 12; mso-yfti-lastrow: yes;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Sedimen</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 22.95pt; mso-add-space: auto; mso-list: l56 level1 lfo41; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Sel epitel</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 22.95pt; mso-add-space: auto; mso-list: l56 level1 lfo41; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Leukosit</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 22.95pt; mso-add-space: auto; mso-list: l56 level1 lfo41; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Eritrosit</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 22.95pt; mso-add-space: auto; mso-list: l56 level1 lfo41; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Kristal</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 22.95pt; mso-add-space: auto; mso-list: l56 level1 lfo41; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Silinder </span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 22.95pt; mso-add-space: auto;">
<span lang="EN-US">Hyalin</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 22.95pt; mso-add-space: auto;">
<span lang="EN-US">Granula</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.35pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<br /></div>
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">1</span></div>
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">10-15</span></div>
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">15-25</span></div>
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">-</span></div>
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<br /></div>
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">+</span></div>
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">+</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 151.9pt;" valign="top" width="203">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<br /></div>
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">1</span></div>
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">0-5/LPB</span></div>
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">0-2/LPB</span></div>
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">-</span></div>
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<br /></div>
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">-</span></div>
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">-</span></div>
</td>
</tr>
</tbody></table>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 2.0cm; mso-add-space: auto;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 2.0cm; mso-add-space: auto;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 71.45pt; mso-add-space: auto; mso-list: l24 level1 lfo40; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Hasil CT SCAN </span></b><span lang="EN-US">31 Mei 2013</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 70.9pt; mso-add-space: auto; text-indent: 35.45pt;">
<span lang="EN-US">Tampak Lesi hyperdens
intraventrikell lateral bilateral terutama dextra dengan HU 44-55. Ventrikel
lateral dan ventrikel III relative melebar sinetris. Tak tampak devisiasi
Struktur mediana</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 70.9pt; mso-add-space: auto; text-indent: 35.45pt;">
<span lang="EN-US">Kesan :
Intraventrikuler Haemorhage</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 2.0cm; mso-add-space: auto;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 71.45pt; mso-add-space: auto; mso-list: l24 level1 lfo40; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Hasil EKG </span></b><span style="mso-ansi-language: IN;">Tanggal 31 Mei 2013</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 71.45pt; mso-add-space: auto;">
<span style="mso-ansi-language: IN;">Sinus Rhytme</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 2.0cm; mso-add-space: auto;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 2.0cm; mso-add-space: auto;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 2.0cm; mso-add-space: auto;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 2.0cm; mso-add-space: auto;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 2.0cm; mso-add-space: auto;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 2.0cm; mso-add-space: auto;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 2.0cm; mso-add-space: auto;">
<br /></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 2.0cm; mso-add-space: auto;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
</div>
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;"><br clear="all" style="mso-break-type: section-break; page-break-before: auto;" />
</span>
<div class="WordSection7">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l24 level1 lfo40; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">T</span><span lang="EN-US">erapi</span></b><b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;"> obat </span></b></div>
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: none; margin-left: -1.7pt; mso-border-alt: solid windowtext .5pt; mso-border-insideh: .5pt solid windowtext; mso-border-insidev: .5pt solid windowtext; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-table-layout-alt: fixed; mso-yfti-tbllook: 1184; width: 936px;">
<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td style="background: #92D050; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 141.8pt;" valign="top" width="189">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Nama obat</span></b></div>
</td>
<td colspan="2" style="background: #92D050; border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 240.95pt;" valign="top" width="321">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Komposisi</span></b></div>
</td>
<td style="background: #92D050; border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 212.65pt;" valign="top" width="284">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Indikasi</span></b></div>
</td>
<td style="background: #92D050; border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.3pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Dosis</span></b></div>
</td>
</tr>
<tr style="mso-yfti-irow: 1;">
<td colspan="5" style="background: #92D050; border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 701.7pt;" valign="top" width="936">
<div align="center" class="MsoListParagraph" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">30 Mei 2013</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 2;">
<td colspan="2" style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 142.1pt;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span style="mso-ansi-language: IN;">C</span><span lang="EN-US">eftriaxon</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 240.65pt;" valign="top" width="321">
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">ceftriaxone sodium setara dengan
ceftriaxone 1,0 g</span><span style="mso-ansi-language: IN;"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 212.65pt;" valign="top" width="284">
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: -18.0pt;">
<span style="mso-ansi-language: IN; mso-fareast-language: IN;"><span style="mso-spacerun: yes;"> </span>pengobatan infeksi saluran nafas bagian
bawah, Otitis media bakteri akut, Infeksi kulit dan struktur kulit</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.3pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">1x2gr</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 3;">
<td colspan="2" style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 142.1pt;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Aminophilin</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 240.65pt;" valign="top" width="321">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Tiap tablet mengandung aminofilin 200
mg</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 212.65pt;" valign="top" width="284">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Asma dan penyakit paru obstruksi
kronis</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.3pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">2 ampul
drip/500ml</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 4;">
<td colspan="2" style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 142.1pt;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Sanmol</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 240.65pt;" valign="top" width="321">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Paracetamol</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 212.65pt;" valign="top" width="284">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Meredakan nyeri termasuk sakit
kepala, sakit gigi, demam yg menyertai flu & stlh imunisasi.</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.3pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">2x1</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 5;">
<td colspan="2" style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 142.1pt;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Brainact</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 240.65pt;" valign="top" width="321">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Citicolin</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 212.65pt;" valign="top" width="284">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Gangguan fungsi kognitif pada lansia</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.3pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">2 x
500 mg</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 6;">
<td colspan="2" style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 142.1pt;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Lapibal</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 240.65pt;" valign="top" width="321">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Mecobalamin</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 212.65pt;" valign="top" width="284">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Neuropati perifer, tinitus, vertigo,
anemia megaloblastik krn defisiensi vit B12. Inj: Neuropati perifer.</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.3pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">2x1 A</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 7;">
<td colspan="2" style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 142.1pt;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Herbrezzer</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 240.65pt;" valign="top" width="321">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span style="mso-ansi-language: IN;">Diltiazem Hcl</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 212.65pt;" valign="top" width="284">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span style="mso-ansi-language: IN;">Takhiaritmia
supraventikular, penangangan penigkatan tekanan darah, yang tidak normal
selama operasi, hipertensi dala keadaan adarurat</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.3pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">Drip</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 8;">
<td colspan="2" style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 142.1pt;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Futrolit</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 240.65pt;" valign="top" width="321">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<b><span lang="EN-US">Per 500 ml</span></b><span lang="EN-US"> NaCl 1.812 g, KCL 0.671 g, CaCl</span><span lang="EN-US" style="font-family: "Cambria Math","serif"; mso-bidi-font-family: "Cambria Math";">₂</span><span lang="EN-US"> dihidrat 0.147 g, MgCl</span><span lang="EN-US" style="font-family: "Cambria Math","serif"; mso-bidi-font-family: "Cambria Math";">₂</span><span lang="EN-US"> hexahidrat 2.586 g, Na asetat trihidrat 0.305 g, sorbitol 25 g,
air untuk injeksi 500 g.<br />
Osmolarity: 475-575 mOsm/L.</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 212.65pt;" valign="top" width="284">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Perbaikan kebutuhan karbohidrat,
cairan & elektrolit pada tahap pre, intra & pasca operasi, dehidrasi
isotonik & kehilangan cairan extracellular.</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.3pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">20tpm</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 9;">
<td colspan="5" style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 701.7pt;" valign="top" width="936">
<div align="center" class="MsoListParagraph" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">31 Mei 2013</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 10;">
<td colspan="2" style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 142.1pt;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Ceftriaxone</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 240.65pt;" valign="top" width="321">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">ceftriaxone sodium setara dengan
ceftriaxone 1,0 g</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 212.65pt;" valign="top" width="284">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span style="mso-ansi-language: IN; mso-fareast-language: IN;">pengobatan infeksi saluran nafas bagian bawah, Otitis media bakteri akut,
Infeksi kulit dan struktur kulit</span><span lang="EN-US"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.3pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">1x2gr</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 11;">
<td colspan="2" style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 142.1pt;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Aminophilin</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 240.65pt;" valign="top" width="321">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Tiap tablet mengandung aminofilin 200
mg</span><span style="mso-ansi-language: IN;"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 212.65pt;" valign="top" width="284">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Asma dan penyakit paru obstruksi
kronis</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.3pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">2 ampul
drip/500ml</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 12;">
<td colspan="2" style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 142.1pt;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Sanmol</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 240.65pt;" valign="top" width="321">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Paracetamol</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 212.65pt;" valign="top" width="284">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Meredakan nyeri termasuk sakit
kepala, sakit gigi, demam yg menyertai flu & stlh imunisasi.</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.3pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">2x1</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 13;">
<td colspan="2" style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 142.1pt;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Brainact</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 240.65pt;" valign="top" width="321">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span style="mso-ansi-language: IN;">Citicolin</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 212.65pt;" valign="top" width="284">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Gangguan fungsi kognitif pada lansia</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.3pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">2 x
500 mg</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 14;">
<td colspan="2" style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 142.1pt;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Lapibal</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 240.65pt;" valign="top" width="321">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Mecobalamin</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 212.65pt;" valign="top" width="284">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Neuropati perifer, tinitus, vertigo,
anemia megaloblastik krn defisiensi vit B12. Inj: Neuropati perifer.</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.3pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">2x1 A</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 15;">
<td colspan="2" style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 142.1pt;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Herbrezzer</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 240.65pt;" valign="top" width="321">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span style="mso-ansi-language: IN;">Diltiazem Hcl</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 212.65pt;" valign="top" width="284">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span style="mso-ansi-language: IN;">Takhiaritmia
supraventikular, penangangan penigkatan tekanan darah, yang tidak normal
selama operasi, hipertensi dala keadaan adarurat</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.3pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">Drip</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 16;">
<td colspan="2" style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 142.1pt;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Futrolit</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 240.65pt;" valign="top" width="321">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<b><span lang="EN-US">Per 500 ml</span></b><span lang="EN-US"> NaCl 1.812 g, KCL 0.671 g, CaCl</span><span lang="EN-US" style="font-family: "Cambria Math","serif"; mso-bidi-font-family: "Cambria Math";">₂</span><span lang="EN-US"> dihidrat 0.147 g, MgCl</span><span lang="EN-US" style="font-family: "Cambria Math","serif"; mso-bidi-font-family: "Cambria Math";">₂</span><span lang="EN-US"> hexahidrat 2.586 g, Na asetat trihidrat 0.305 g, sorbitol 25 g,
air untuk injeksi 500 g.<br />
Osmolarity: 475-575 mOsm/L.</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 212.65pt;" valign="top" width="284">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Perbaikan kebutuhan karbohidrat,
cairan & elektrolit pada tahap pre, intra & pasca operasi, dehidrasi
isotonik & kehilangan cairan extracellular.</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.3pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">20tpm</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 17;">
<td colspan="5" style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 701.7pt;" valign="top" width="936">
<div align="center" class="MsoListParagraph" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">1 juni 2013</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 18;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 141.8pt;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Ceftriaxone</span></div>
</td>
<td colspan="2" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 240.95pt;" valign="top" width="321">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">ceftriaxone sodium setara dengan
ceftriaxone 1,0 g</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 212.65pt;" valign="top" width="284">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span style="mso-ansi-language: IN; mso-fareast-language: IN;">pengobatan infeksi saluran nafas bagian bawah, Otitis media bakteri akut,
Infeksi kulit dan struktur kulit</span><span lang="EN-US"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.3pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">1x2gr</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 19;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 141.8pt;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Aminophilin</span></div>
</td>
<td colspan="2" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 240.95pt;" valign="top" width="321">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Tiap tablet mengandung aminofilin 200
mg</span><span style="mso-ansi-language: IN;"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 212.65pt;" valign="top" width="284">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Asma dan penyakit paru obstruksi
kronis</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.3pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">2 ampul
drip/500ml</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 20;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 141.8pt;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Kalnex</span></div>
</td>
<td colspan="2" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 240.95pt;" valign="top" width="321">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Tiap ml S injeksi (10 w/v %)
mengandung Tranexamic acid100 mg</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 212.65pt;" valign="top" width="284">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Untuk fibrinolisis lokal seperti
epistaksi, prostatektomi, konisasi serviks</span><span style="mso-ansi-language: IN;">, </span><span lang="EN-US">Edema angioneurotik hereditas</span><span style="mso-ansi-language: IN;">, </span><span lang="EN-US">Pendarahan abnormal
sesudah operasi secara umum</span><span style="mso-ansi-language: IN;">, </span><span lang="EN-US">Pendarahan sesudah operasi gigi pada penderita haemofilia</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.3pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">3x500mg</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 21;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 141.8pt;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Brainact</span></div>
</td>
<td colspan="2" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 240.95pt;" valign="top" width="321">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span style="mso-ansi-language: IN;">Citicolin</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 212.65pt;" valign="top" width="284">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Gangguan fungsi kognitif pada lansia</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.3pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">2 x
500 mg</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 22;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 141.8pt;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Lapibal</span></div>
</td>
<td colspan="2" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 240.95pt;" valign="top" width="321">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Mecobalamin</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 212.65pt;" valign="top" width="284">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Neuropati perifer, tinitus, vertigo,
anemia megaloblastik krn defisiensi vit B12</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.3pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">2x1 A</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 23; mso-yfti-lastrow: yes;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 141.8pt;" valign="top" width="189">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span lang="EN-US">Herbrezzer</span></div>
</td>
<td colspan="2" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 240.95pt;" valign="top" width="321">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span style="mso-ansi-language: IN;">Diltiazem Hcl</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 212.65pt;" valign="top" width="284">
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span style="mso-ansi-language: IN;">Takhiaritmia
supraventikular, penangangan penigkatan tekanan darah, yang tidak normal
selama operasi, hipertensi dala keadaan adarurat</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.3pt;" valign="top" width="142">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">Drip</span></div>
</td>
</tr>
<tr height="0">
<td style="border: none;" width="189"><br /></td>
<td style="border: none;" width="0"><br /></td>
<td style="border: none;" width="321"><br /></td>
<td style="border: none;" width="284"><br /></td>
<td style="border: none;" width="142"><br /></td>
</tr>
</tbody></table>
</div>
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;"><br clear="all" style="mso-break-type: section-break; page-break-before: auto;" />
</span></b>
<div class="WordSection8">
<div class="MsoListParagraph" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l24 level1 lfo40; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Pathway Kasus</span></b><b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;"></span></b></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US">Hipertensi</span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US"> </span></div>
<br clear="ALL" style="mso-ignore: vglayout;" />
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US">Penimbunan
lemak/kolesterol yang meningkat</span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US">dalam darah<span style="mso-tab-count: 1;"> </span></span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US">Lemak nekrotik dan berdegenerasi</span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
<div class="MsoNormal" style="margin-left: 58.5pt; tab-stops: 13.5pt 252.0pt 504.0pt; text-align: justify; text-indent: 229.5pt;">
<span lang="EN-US">Infiltrasi limfosit (trombus)<span style="mso-spacerun: yes;"> </span><span style="mso-tab-count: 1;"> </span><span style="mso-spacerun: yes;"> </span>Penyempitan pembuluh darah</span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
<div class="MsoNormal" style="tab-stops: 252.0pt 504.0pt; text-align: justify; text-indent: 292.5pt;">
<span lang="EN-US">Pembuluh darah menjadi kaku <span style="mso-tab-count: 1;"> </span>Tekanan Kapiler meningkat</span></div>
<div class="MsoNormal" style="tab-stops: 252.0pt 504.0pt; text-align: justify;">
<span lang="EN-US"> </span></div>
<br clear="ALL" style="mso-ignore: vglayout;" />
<div class="MsoNormal" style="tab-stops: 306.0pt 504.0pt; text-align: justify;">
<span lang="EN-US"><span style="mso-tab-count: 1;"> </span>Pembuluh
darah pecah<span style="mso-tab-count: 1;"> </span>Peningkatan
volume interstisial</span></div>
<div class="MsoNormal" style="tab-stops: 252.0pt 504.0pt; text-align: justify;">
<span lang="EN-US"> </span></div>
<br clear="ALL" style="mso-ignore: vglayout;" />
<div class="MsoNormal" style="tab-stops: 310.5pt 553.5pt; text-align: justify;">
<span lang="EN-US"><span style="mso-tab-count: 1;"> </span>Stroke
hemoragic<span style="mso-tab-count: 1;"> </span>Udema</span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US"> </span></div>
<br clear="ALL" style="mso-ignore: vglayout;" />
<div class="MsoNormal" style="tab-stops: 252.0pt 504.0pt;">
</div>
<table cellpadding="0" cellspacing="0" style="width: 100%px;">
<tbody>
<tr>
<td>
<div>
<div class="MsoNormal" style="tab-stops: 252.0pt 504.0pt;">
<span lang="EN-US">Kelebihan
Volume Cairan</span></div>
<div class="MsoNormal">
<br /></div>
</div>
</td>
</tr>
</tbody></table>
<span lang="EN-US">Proses metabolisme dalam otak terganggu<span style="mso-tab-count: 1;"> </span>Penurunan suplay darah & O<sub>2</sub>
ke otak<span style="mso-tab-count: 1;"> </span></span>
<div class="MsoNormal">
</div>
<table cellpadding="0" cellspacing="0" style="width: 100%px;">
<tbody>
<tr>
<td>
<div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US">Ketidakefektifan
perfusi jaringan serebral</span></div>
</div>
</td>
</tr>
</tbody></table>
<span lang="EN-US"> </span>
<div class="MsoNormal">
<br /></div>
<br clear="ALL" style="mso-ignore: vglayout;" />
<div class="MsoNormal">
<span lang="EN-US"><span style="mso-tab-count: 4;"> </span>Peningkatan
TIK</span></div>
<div class="MsoNormal">
<span lang="EN-US"> </span></div>
<div class="MsoNormal">
<br /></div>
<br clear="ALL" style="mso-ignore: vglayout;" />
<div class="MsoNormal">
<span lang="EN-US">Arteri vertebra basilasris<span style="mso-tab-count: 1;"> </span>Penurunan fungsi N. IX dan X<span style="mso-tab-count: 1;"> </span></span></div>
<div class="MsoNormal">
<span lang="EN-US"> </span></div>
<br clear="ALL" style="mso-ignore: vglayout;" />
<div class="MsoNormal">
<span lang="EN-US"><span style="mso-spacerun: yes;"> </span>Disfungsi N
XI<span style="mso-tab-count: 2;"> </span>Proses menelan tidak
efektif</span></div>
<div class="MsoNormal">
<span lang="EN-US"><span style="mso-spacerun: yes;">
</span>(Assesorius)</span></div>
<div class="MsoNormal">
<span lang="EN-US"><span style="mso-tab-count: 5;"> </span>Refluks<span style="mso-tab-count: 3;"> </span>Disfagia</span></div>
<div class="MsoNormal">
<span lang="EN-US">Kelemahan Anggota</span></div>
<div class="MsoNormal">
</div>
<table cellpadding="0" cellspacing="0" style="width: 100%px;">
<tbody>
<tr>
<td>
<div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US">Ketidakseimbangan
nutrisi kurang dari kebutuhan tubuh</span></div>
</div>
</td>
</tr>
</tbody></table>
<span lang="EN-US"><span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>Gerak</span>
<div class="MsoNormal">
</div>
<table cellpadding="0" cellspacing="0" style="width: 100%px;">
<tbody>
<tr>
<td>
<div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US">Kerusakan</span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US"><span style="mso-spacerun: yes;"> </span>Mobilitas Fisik</span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</div>
</td>
</tr>
</tbody></table>
<table cellpadding="0" cellspacing="0" style="width: 100%px;">
<tbody>
<tr>
<td>
<div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US">Defisit </span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US">Perawatan Diri</span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</div>
</td>
</tr>
</tbody></table>
<span lang="EN-US"> </span>
</div>
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;"><br clear="all" style="mso-break-type: section-break; page-break-before: always;" />
</span>
<div class="WordSection9">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<br clear="ALL" style="mso-ignore: vglayout;" />
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l65 level1 lfo37; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">K.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Analisa Data</span><span lang="EN-US"></span></b></div>
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: none; margin-left: 26.7pt; mso-border-alt: solid windowtext .5pt; mso-border-insideh: .5pt solid windowtext; mso-border-insidev: .5pt solid windowtext; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-yfti-tbllook: 1184;">
<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td style="border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 216.1pt;" valign="top" width="288">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Analisa data</span></b></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 109.9pt;" valign="top" width="147">
<div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Etiologi</span></b></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 109.4pt;" valign="top" width="146">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Masalah</span></b></div>
</td>
</tr>
<tr style="height: 220.8pt; mso-yfti-irow: 1;">
<td style="border-top: none; border: solid windowtext 1.0pt; height: 220.8pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 216.1pt;" valign="top" width="288">
<div class="MsoNormal" style="line-height: 150%;">
<span lang="SV" style="mso-ansi-language: SV;">Data Subyektif : -</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="SV" style="mso-ansi-language: SV;">Data Obyektif<span style="mso-spacerun: yes;"> </span>:</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.85pt; mso-list: l53 level1 lfo38; text-indent: -14.2pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Tingkat kesadaran : sopor</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.85pt; mso-list: l53 level1 lfo38; text-indent: -14.2pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">GCS </span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.85pt;">
<span lang="SV" style="mso-ansi-language: SV;">E : 2<span style="mso-spacerun: yes;"> </span>V:</span><span lang="EN-US">2</span><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-spacerun: yes;"> </span>M :</span><span lang="EN-US">2</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.85pt; mso-list: l53 level1 lfo38; text-indent: -14.2pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Klien mengalami kelemahan pada anggota gerak sebelah kanan</span><span lang="SV" style="mso-ansi-language: SV;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.85pt; mso-list: l53 level1 lfo38; text-indent: -14.2pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Klien tampak lemah </span><span lang="SV" style="mso-ansi-language: SV;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.85pt; mso-list: l53 level1 lfo38; text-indent: -14.2pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">e.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Klien memiliki riwayat stroke sekitar 1
tahun yang lalu.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.85pt; mso-list: l53 level1 lfo38; text-indent: -14.2pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">f.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Pupil isokor, diameter kanan/kiri 2mm/2mm, reaksi cahaya +/+.</span><span lang="SV" style="mso-ansi-language: SV;"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 220.8pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 109.9pt;" valign="top" width="147">
<div align="center" class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">Gangguan
aliran arteri atau vena</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 220.8pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 109.4pt;" valign="top" width="146">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">Ketidakefektifan
perfusi jaringan serebral</span></div>
</td>
</tr>
<tr style="height: 166.8pt; mso-yfti-irow: 2;">
<td style="border-top: none; border: solid windowtext 1.0pt; height: 166.8pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 216.1pt;" valign="top" width="288">
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US">Data Subyektif :
-</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US">Data Obyektif :</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l81 level1 lfo44; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Klien mengalami kelemahan
pada ekstrimitas sebelah kanan</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l81 level1 lfo44; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Klien tidak mampu melakukan
perawatan diri mandi/hygiene, berpakaian/berhias, makan dan eliminasi karena
mengalami penurunan kesadaran</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 166.8pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 109.9pt;" valign="top" width="147">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="EN-US">Kelemahan</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 166.8pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 109.4pt;" valign="top" width="146">
<div align="center" class="MsoListParagraph" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">Defisit Perawatan
Diri Total</span></div>
</td>
</tr>
<tr style="height: 20.8pt; mso-yfti-irow: 3;">
<td style="border-top: none; border: solid windowtext 1.0pt; height: 20.8pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 216.1pt;" valign="top" width="288">
<div class="MsoNormal" style="line-height: 150%;">
<span lang="SV" style="mso-ansi-language: SV;">Data Subyektif : -</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="SV" style="mso-ansi-language: SV;">Data Obyektif :</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l61 level1 lfo42; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Klien
tampak lemah</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l61 level1 lfo42; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Klien
mengalami kelemahan pada anggota gerak sebelah kanan</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l61 level1 lfo42; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Klien
mengalami penurunan kesadaran</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l61 level1 lfo42; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Tingkat
kesadaran : sopor</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l61 level1 lfo42; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">e.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Vital
Sign:</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; tab-stops: 108.0pt; text-align: justify;">
<span style="mso-ansi-language: IN;">TD<span style="mso-tab-count: 1;"> </span>:
</span><span lang="EN-US">201/133 mmHg</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto;">
<span lang="EN-US">MAP<span style="mso-tab-count: 2;"> </span>:
</span><span style="mso-ansi-language: IN;">137</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto;">
<span style="mso-ansi-language: IN;">HR<span style="mso-tab-count: 3;"> </span>: </span><span lang="EN-US">6</span><span style="mso-ansi-language: IN;">4 x/menit</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto;">
<span lang="EN-US">RR<span style="mso-spacerun: yes;"> </span>: 2</span><span style="mso-ansi-language: IN;">4</span><span lang="EN-US"> x/menit</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto;">
<span lang="EN-US">SPO<sub>2</sub></span><sub><span style="mso-ansi-language: IN;"><span style="mso-spacerun: yes;"> </span></span></sub><span lang="EN-US">: 99%</span><span lang="SV" style="mso-ansi-language: SV;"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 20.8pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 109.9pt;" valign="top" width="147">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="EN-US">Kontraktur atau kaku sendi</span><span style="mso-ansi-language: IN;"></span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; text-align: justify;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 20.8pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 109.4pt;" valign="top" width="146">
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">Hambatan
mobilitas Fisik</span></div>
</td>
</tr>
<tr style="height: 208.7pt; mso-yfti-irow: 4;">
<td style="border-top: none; border: solid windowtext 1.0pt; height: 208.7pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 216.1pt;" valign="top" width="288">
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US">Data Subyektif :
</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US">Keluarga
mengatakan Selama di Rumah sakit selama 8 hari sebelum masuk ICU pasien minum
susu dari rumah sakit melalui NGT </span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US">Data Obyektif :</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l111 level1 lfo43; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Klien mengalami penurunan
kesadaran</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l111 level1 lfo43; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Tingkat kesadaran : Sopor</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l111 level1 lfo43; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Membran mukosa kering</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l111 level1 lfo43; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Konjungtiva pucat</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l111 level1 lfo43; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">e.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Terpasang NGT dengan residu
berwarna kuning</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l111 level1 lfo43; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">f.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Bising usus </span><span style="mso-ansi-language: IN;">8</span><span lang="EN-US"> x/menit</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l111 level1 lfo43; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">g.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Klien mengalami kelemahan
otot </span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l111 level1 lfo43; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">h.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">LLA :</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="EN-US">35 cm</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto;">
<span style="mso-ansi-language: IN; mso-fareast-language: IN; mso-no-proof: yes;">
</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto;">
<span style="mso-ansi-language: IN;">Interprestasi LILA
122 (Obesitas)</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l111 level1 lfo43; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">i.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Edema pada Ekstermitas atas
dan ekstermitas bawah</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l111 level1 lfo43; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">j.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Turgor kulit buruk</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l111 level1 lfo43; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">k.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">WBC</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="EN-US">7,36</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l111 level1 lfo43; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">l.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">RBC</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="EN-US">4,47</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l111 level1 lfo43; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">m.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">HGB</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="EN-US">12,0</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l111 level1 lfo43; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">n.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">HCT</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="EN-US">7,0</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l111 level1 lfo43; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">o.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">PLT</span><span style="mso-ansi-language: IN;"> 356</span><span lang="EN-US"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 208.7pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 109.9pt;" valign="top" width="147">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="EN-US">Penyakit kronis (Stroke)</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 208.7pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 109.4pt;" valign="top" width="146">
<div align="center" class="MsoListParagraph" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">Ketidakseimbangan
nutrisi kurang dari kebutuhan tubuh</span></div>
</td>
</tr>
<tr style="height: 208.7pt; mso-yfti-irow: 5; mso-yfti-lastrow: yes;">
<td style="border-top: none; border: solid windowtext 1.0pt; height: 208.7pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 216.1pt;" valign="top" width="288">
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US">DS=-</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US">Data Obyektif</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 18.3pt; mso-add-space: auto; mso-list: l26 level4 lfo22; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Klien mengalami edema pada
ekstermitas atas dan bawah</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.3pt; mso-add-space: auto; mso-list: l26 level4 lfo22; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">TD<span style="mso-tab-count: 1;"> </span>: 201/133 mmHg</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.3pt; mso-add-space: auto; mso-list: l26 level4 lfo22; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">HR<span style="mso-tab-count: 1;"> </span>: 64 x/menit</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 18.3pt; mso-add-space: auto; mso-list: l26 level4 lfo22; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Turgor kulit<span style="mso-tab-count: 1;"> </span>: Buruk</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 18.3pt; mso-add-space: auto; mso-list: l26 level4 lfo22; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">e.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="mso-ansi-language: IN;">Balance
cairan 24 jam tanggal 31 mei </span><span lang="EN-US"></span></div>
<div style="margin-bottom: .0001pt; margin: 0cm;">
<strong><span style="font-size: 11.0pt; font-weight: normal; mso-bidi-font-weight: bold;">Balance cairan = Intake
cairan – Output Cairam</span></strong></div>
<div style="margin-bottom: .0001pt; margin: 0cm;">
<strong><span style="font-size: 11.0pt; font-weight: normal; mso-bidi-font-weight: bold;"> <span style="mso-spacerun: yes;"> </span>1200 cc – 1650 cc</span></strong></div>
<div style="margin-bottom: .0001pt; margin: 0cm;">
<strong><span style="font-size: 11.0pt; font-weight: normal; mso-bidi-font-weight: bold;">
= + 450 cc </span></strong></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 208.7pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 109.9pt;" valign="top" width="147">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="EN-US">Gangguan mekanisme regulasi</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 208.7pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 109.4pt;" valign="top" width="146">
<div align="center" class="MsoListParagraph" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span lang="EN-US">Kelebihan volume
cairan</span></div>
</td>
</tr>
</tbody></table>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l65 level1 lfo37; text-indent: -17.85pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">L.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Diagnosa keperawatan</span></b></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l96 level1 lfo39; text-align: justify; text-indent: -14.7pt;">
<span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="mso-ansi-language: IN;">Ketidakefektifan
</span><span lang="EN-US">perfusi jaringan cerebral </span><span style="mso-ansi-language: IN;">b/dgangguan </span><span lang="EN-US">aliran arteri
atau vena</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l96 level1 lfo39; text-align: justify; text-indent: -14.7pt;">
<span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Kelebihan Volume cairan b.d
Gangguan mekanisme regulasi</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l96 level1 lfo39; text-align: justify; text-indent: -14.7pt;">
<span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Ketidakseimbangan nutrisi
kurang dari kebutuhan tubuh </span><span style="mso-ansi-language: IN;">b/d</span><span lang="EN-US"> penyakit kronis (Stroke)</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l96 level1 lfo39; text-align: justify; text-indent: -14.7pt;">
<span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Defisit perawatan diri total </span><span style="mso-ansi-language: IN;">b/d</span><span lang="EN-US"> kelemahan</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l96 level1 lfo39; text-align: justify; text-indent: -14.7pt;">
<span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Hambatan mobilitas fisik </span><span style="mso-ansi-language: IN;">b/d</span><span lang="EN-US"> kaku sendi atau
kontraktur</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<br /></div>
</div>
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN; mso-bidi-language: AR-SA; mso-fareast-font-family: SimSun; mso-fareast-language: ZH-CN;"><br clear="all" style="mso-break-type: section-break; page-break-before: auto;" />
</span>
<div class="WordSection10">
<div class="MsoNormal" style="line-height: 150%;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">M. <i style="mso-bidi-font-style: normal;">Nursing Care
Plan</i></span></b></div>
<div align="center">
<table border="1" cellpadding="0" cellspacing="0" class="MsoTableGrid" style="border-collapse: collapse; border: none; mso-border-alt: solid windowtext .5pt; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-yfti-tbllook: 1184;">
<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td style="border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 33.75pt;" valign="top" width="45">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">No</span></b></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 4.0cm;" valign="top" width="151">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Diagnosa Keperawatan</span></b></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 262.25pt;" width="350">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">NOC</span></b></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 249.4pt;" width="333">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">NIC</span></b></div>
</td>
</tr>
<tr style="mso-yfti-irow: 1;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 33.75pt;" valign="top" width="45">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="EN-US">1</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 4.0cm;" valign="top" width="151">
<div class="MsoNormal" style="line-height: 150%;">
<span style="mso-ansi-language: IN;">Ketidakefektifan </span><span lang="EN-US">perfusi jaringan cerebral
berhubungan dengan gangguan aliran arteri atau vena</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 262.25pt;" valign="top" width="350">
<div class="MsoNormal" style="line-height: 150%;">
<b><span lang="EN-US">NOC :</span></b></div>
<div class="MsoNormal" style="line-height: 150%; tab-stops: list 156.0pt;">
<span lang="EN-US">Circulation status</span></div>
<div class="MsoNormal" style="line-height: 150%; tab-stops: list 192.0pt;">
<span lang="EN-US" style="mso-bidi-font-weight: bold;">Setelah dilakukan asuhan
keperawatan<span style="mso-spacerun: yes;"> </span>selama 3x24 jam diharapkan
ketidakefektifan perfusi jaringan cerebral teratasi dengan kriteria hasil</span><span lang="NL" style="mso-ansi-language: NL;">:</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l45 level1 lfo45; tab-stops: list 90.0pt 108.0pt; text-indent: -18.0pt;">
<span lang="NL" style="font-family: Wingdings; mso-ansi-language: NL; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="mso-ansi-language: NL;">Tekanan systole dan diastole dalam
rentang normal</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt;">
<span lang="NL" style="mso-ansi-language: NL;">TD : Sistole<span style="mso-spacerun: yes;">
</span>: 120-140 mmHg</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt;">
<span lang="NL" style="mso-ansi-language: NL;"><span style="mso-spacerun: yes;">
</span>Diastole : 70 – 90 mmHg</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt;">
<span lang="NL" style="mso-ansi-language: NL;">HR : 60 – 100 x /menit</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt;">
<span lang="NL" style="mso-ansi-language: NL;">RR : 15-22 x/menit</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt;">
<span lang="NL" style="mso-ansi-language: NL;">S<span style="mso-spacerun: yes;"> </span>: 36
– 37,5ºC</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l45 level1 lfo45; tab-stops: list 90.0pt 108.0pt 135.0pt; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Pupil seimbang dan reaktif. Diameter kanan/kiri</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; tab-stops: list 135.0pt;">
<span lang="EN-US">2/2, reaksi +/+</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l45 level1 lfo45; tab-stops: list 90.0pt 108.0pt 135.0pt; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Bebas dari aktivitas kejang</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l45 level1 lfo45; tab-stops: list 90.0pt 108.0pt 135.0pt; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Tingkat kesadaran samnolen</span></div>
<div class="MsoNormal" style="line-height: 150%; tab-stops: list 135.0pt;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; tab-stops: list 135.0pt;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 249.4pt;" valign="top" width="333">
<div class="MsoBodyTextIndent2" style="margin-left: 0cm;">
<b><span lang="EN-US">NIC :</span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US"></span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.65pt; mso-list: l68 level1 lfo46; tab-stops: list 36.0pt; text-indent: -18.0pt;">
<span lang="FI" style="font-family: Wingdings; mso-ansi-language: FI; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Monitor TTV</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.65pt; mso-list: l68 level1 lfo46; tab-stops: list 36.0pt; text-indent: -18.0pt;">
<span lang="FI" style="font-family: Wingdings; mso-ansi-language: FI; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Monitor GCS, ukuran pupil, ketajaman,
kesimetrisan dan reaksi</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.65pt; mso-list: l68 level1 lfo46; tab-stops: list 36.0pt; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Monitor adanya diplopia, pandangan
kabur, nyeri kepala</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.65pt; mso-list: l68 level1 lfo46; tab-stops: list 36.0pt; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Monitor level kebingungan dan orientasi</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.65pt; mso-list: l68 level1 lfo46; tab-stops: list 36.0pt; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Monitor tonus otot pergerakan </span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.65pt; mso-list: l68 level1 lfo46; tab-stops: list 36.0pt; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Pertahankan pemberian O<sub>2</sub></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.65pt; mso-list: l68 level1 lfo46; tab-stops: list 36.0pt; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Catat perubahan pasien dalam merespon
stimulus</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.65pt; mso-list: l68 level1 lfo46; tab-stops: list 36.0pt; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Monitor status cairan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.65pt; mso-list: l68 level1 lfo46; tab-stops: list 36.0pt; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Kolaborasi pemberian obat neuroprotektif</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 2;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 33.75pt;" valign="top" width="45">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="EN-US">2</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 4.0cm;" valign="top" width="151">
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US">Kelebihan Volume
cairan b.d gangguan mekanisme regulasi</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 262.25pt;" valign="top" width="350">
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US">Setelah
dilakukan asuhan keperawatan selama 3x 24 jam maka volume cairan seimbang
dengan indikator:</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 16.9pt; mso-add-space: auto; mso-list: l107 level1 lfo130; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-bidi-font-weight: bold; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">volume cairan stabil dengan keseimbangan masukan danpengeluaran</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 16.9pt; mso-add-space: auto; mso-list: l107 level1 lfo130; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-bidi-font-weight: bold; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">bunyi nafas bersih/jelas</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 16.9pt; mso-add-space: auto; mso-list: l107 level1 lfo130; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-bidi-font-weight: bold; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">tanda vital dalam rentang yang dapat diterima, berat badan stabil </span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 16.9pt; mso-add-space: auto; mso-list: l107 level1 lfo130; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-bidi-font-weight: bold; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">tidak ada edema</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 249.4pt;" valign="top" width="333">
<div class="MsoBodyTextIndent2" style="margin-left: 20.15pt; mso-list: l50 level1 lfo131; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pantau pengeluaran urine,
catat jumlah dan warna saat dimana diuresis terjadi.<br />
Rasional: Pengeluaran urine mungkin sedikit dan pekat karena penurunan
perfusi ginjal. Posisi terlentang membantu diuresis sehingga pengeluaran
urine dapat ditingkatkan selama tirah baring.</span></div>
<div class="MsoBodyTextIndent2" style="margin-left: 20.15pt; mso-list: l50 level1 lfo131; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pantau/hitung keseimbangan
pemasukan dan pengeluaran selama 24 jam<br />
Rasional: Terapi diuretic dapat disebabkan oleh kehilangan cairan
tibatiba/berlebihan (hipovolemia) meskipun edema/asites masih ada.</span></div>
<div class="MsoBodyTextIndent2" style="margin-left: 20.15pt; mso-list: l50 level1 lfo131; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pertahakan duduk atau tirah
baring dengan posisi semifowler selama fase akut.<br />
Rasional: Posisi tersebut meningkatkan filtrasi ginjal dan menurunkan
produksi ADH sehingga meningkatkan diuresis.</span></div>
<div class="MsoBodyTextIndent2" style="margin-left: 20.15pt; mso-list: l50 level1 lfo131; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pantau TD dan CVP (bila ada)<br />
Rasional: Hipertensi dan peningkatan CVP menunjukkan kelebihan cairan dan
dapat menunjukkan terjadinya peningkatan kongesti paru, gagal jantung.</span></div>
<div class="MsoBodyTextIndent2" style="margin-left: 20.15pt; mso-list: l50 level1 lfo131; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">e.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Kaji bisisng usus. Catat
keluhan anoreksia, mual, distensi abdomen dan konstipasi.<br />
Rasional: Kongesti visceral (terjadi pada GJK lanjut) dapat mengganggu fungsi
gaster/intestinal.</span></div>
<div class="MsoBodyTextIndent2" style="margin-left: 20.15pt; mso-list: l50 level1 lfo131; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">f.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pemberian obat sesuai
indikasi (kolaborasi)</span></div>
<div class="MsoBodyTextIndent2" style="margin-left: 20.15pt; mso-list: l50 level1 lfo131; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">g.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Konsul dengan ahli diet.<br />
Rasional: perlu memberikan diet yang dapat diterima klien yang memenuhi
kebutuhan kalori dalam pembatasan natrium.</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 3;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 33.75pt;" valign="top" width="45">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="EN-US">3</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 4.0cm;" valign="top" width="151">
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US">Ketidakseimbangan
nutrisi kurang dari kebutuhan tubuh berhubungan dengan kesulitan menelan dan
mengunyah</span><span style="mso-ansi-language: IN;"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 262.25pt;" valign="top" width="350">
<div class="MsoNormal" style="line-height: 150%;">
<b><span lang="FI" style="mso-ansi-language: FI;">NOC:</span></b></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="FI" style="mso-ansi-language: FI; mso-bidi-font-weight: bold;">Nutritional status: Adequacy of nutrient</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="FI" style="mso-ansi-language: FI; mso-bidi-font-weight: bold;">Setelah dilakukan tindakan keperawatan selama
3x 24 jam, diharapkan nutrisi kurang teratasi dengan kriteria hasil :</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.9pt; mso-add-space: auto; mso-list: l106 level1 lfo49; text-align: justify; text-indent: -18.0pt;">
<span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Memiliki nilai laboratorium
dalam batas normal</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.9pt; mso-add-space: auto; mso-list: l106 level1 lfo49; text-align: justify; text-indent: -18.0pt;">
<span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Mempertahankan massa tubuh
dan berat badan dalam batas normal 60-64 kg</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.9pt; mso-add-space: auto; mso-list: l106 level1 lfo49; text-align: justify; text-indent: -18.0pt;">
<span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Mentoleransi diet yang
dianjurkan</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 15.9pt; mso-add-space: auto; mso-list: l106 level1 lfo49; text-align: justify; text-indent: -18.0pt;">
<span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Tidak ada muntah</span><span style="mso-ansi-language: IN;"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 249.4pt;" valign="top" width="333">
<div class="MsoNormal" style="line-height: 150%; margin-left: 22.95pt; mso-list: l42 level1 lfo50; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Kaji adanya alergi makanan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 22.95pt; mso-list: l42 level1 lfo50; text-align: justify; text-indent: -18.0pt;">
<span lang="NL" style="mso-ansi-language: NL;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Kolaborasi dengan ahli gizi untuk menentukan jumlah kalori dan
nutrisi yang dibutuhkan pasien</span><span lang="NL" style="mso-ansi-language: NL;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 22.95pt; mso-list: l42 level1 lfo50; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Monitor adanya penurunan BB dan gula
darah</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 22.95pt; mso-list: l42 level1 lfo50; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Monitor turgor kulit</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 22.95pt; mso-list: l42 level1 lfo50; text-align: justify; text-indent: -18.0pt;">
<span lang="NL" style="mso-ansi-language: NL;"><span style="mso-list: Ignore;">e.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Monitor kekeringan, rambut kusam, total
protein, Hb dan kadar Ht</span><span lang="NL" style="mso-ansi-language: NL;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 22.95pt; mso-list: l42 level1 lfo50; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">f.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Monitor mual dan muntah</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 22.95pt; mso-list: l42 level1 lfo50; text-align: justify; text-indent: -18.0pt;">
<span lang="NL" style="mso-ansi-language: NL;"><span style="mso-list: Ignore;">g.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="mso-ansi-language: NL;">Monitor pucat, kemerahan, dan kekeringan
jaringan konjungtiva</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 22.95pt; mso-list: l42 level1 lfo50; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">h.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Monitor intake nutrisi</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 22.95pt; mso-list: l42 level1 lfo50; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">i.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Atur posisi semi fowler atau
fowler tinggi selama makan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 22.95pt; mso-list: l42 level1 lfo50; text-align: justify; text-indent: -18.0pt;">
<span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">j.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI;">Pertahankan
terapi IV line</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 4;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 33.75pt;" valign="top" width="45">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="EN-US">4</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 4.0cm;" valign="top" width="151">
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US">Defisit perawatn
diri total berhubungan dengan intoleransi aktivitas</span><span style="mso-ansi-language: IN;"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 262.25pt;" valign="top" width="350">
<div class="MsoNormal" style="line-height: 150%;">
<i style="mso-bidi-font-style: normal;"><span lang="EN-US">Self care : Activity of Daily Living (ADLs</span></i><span lang="EN-US">)</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="FI" style="mso-ansi-language: FI; mso-bidi-font-weight: bold;">Setelah dilakukan tindakan keperawatan selama 3
x 24 jam diharapkan defisit perawatan diri teratas dengan kriteria hasil:</span><b><span lang="EN-US"></span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 16.25pt; mso-list: l69 level1 lfo51; tab-stops: list 16.25pt 72.0pt; text-indent: -16.25pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Klien terbebas dari bau badan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 16.25pt; mso-list: l69 level1 lfo51; tab-stops: list 16.25pt 72.0pt; text-indent: -16.25pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Dapat melakukan ADLS dengan bantuan</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 249.4pt;" valign="top" width="333">
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US">S<b>elf Care
assistane : ADLs</b></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.65pt; mso-list: l33 level1 lfo52; tab-stops: list 21.65pt 36.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Monitor kemampuan klien untuk perawatan
diri yang mandiri.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.65pt; mso-list: l33 level1 lfo52; tab-stops: list 21.65pt 36.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Monitor kebutuhan klien untuk alat-alat bantu untuk kebersihan
diri, berpakaian, berhias, toileting dan makan.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.65pt; mso-list: l33 level1 lfo52; tab-stops: list 21.65pt 36.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Sediakan bantuan sampai klien mampu secara utuh untuk melakukan
self-care.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 3.65pt;">
<br /></div>
</td>
</tr>
<tr style="mso-yfti-irow: 5; mso-yfti-lastrow: yes;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 33.75pt;" valign="top" width="45">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="EN-US">5</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 4.0cm;" valign="top" width="151">
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US">Hambatan
mobilitas fisik</span><span style="mso-ansi-language: IN;"> b</span><span lang="EN-US">erhubungan dengan kaku sendi atau kontraktur</span><span style="mso-ansi-language: IN;"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 262.25pt;" valign="top" width="350">
<div class="MsoNormal" style="line-height: 150%;">
<b><span lang="EN-US">NOC : </span></b></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US">Mobilisasi</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="FI" style="mso-ansi-language: FI;">Setelah dilakukan tindakan keperawatan selama 3x24 jam diharapkan klien
mobilisasi di tempat tidur </span><span lang="SV" style="mso-ansi-language: SV;">dengan <span style="mso-bidi-font-weight: bold;">Kriteria Hasil :</span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 19.15pt; mso-list: l41 level1 lfo47; tab-stops: list 19.15pt 81.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Berpartisipasi dalam aktivitas fisik
tanpa disertai peningkatan tekanan darah, nadi dan RR</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 19.15pt; mso-list: l41 level1 lfo47; tab-stops: list 19.15pt 81.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">v<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Keseimbangan aktivitas dan istirahat</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 249.4pt;" valign="top" width="333">
<div class="MsoBodyTextIndent2" style="margin-left: 0cm;">
<b><span lang="EN-US">NIC :</span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US"></span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 22.95pt; mso-list: l9 level1 lfo48; text-align: justify; text-indent: -18.0pt;">
<span lang="NL" style="mso-ansi-language: NL;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="mso-ansi-language: NL;">Monitor nutrisi<span style="mso-spacerun: yes;"> </span>dan sumber energi yang adekuat</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 22.95pt; mso-list: l9 level1 lfo48; text-align: justify; text-indent: -18.0pt;">
<span lang="NL" style="mso-ansi-language: NL;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="mso-ansi-language: NL;">Monitor respon kardiovaskuler<span style="mso-spacerun: yes;"> </span>terhadap aktivitas (takikardi, disritmia,
sesak nafas, diaporesis, pucat, perubahan hemodinamik)</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 22.95pt; mso-list: l9 level1 lfo48; text-align: justify; text-indent: -18.0pt;">
<span lang="IT" style="mso-ansi-language: IT;"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="IT" style="mso-ansi-language: IT;">Monitor pola tidur dan lamanya tidur/istirahat
pasien</span></div>
<div class="MsoBodyTextIndent2" style="margin-left: 22.95pt; mso-list: l9 level1 lfo48; text-indent: -18.0pt;">
<span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Pantau respon oksigen pasien terhadap
aktivitas keperawatan</span></div>
<div class="MsoBodyTextIndent2" style="margin-left: 22.95pt; mso-list: l9 level1 lfo48; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">e.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI;">Bantu
pasien untuk mengubah posisi secara berkala</span><span lang="EN-US"></span></div>
<div class="MsoBodyTextIndent2" style="margin-left: 22.95pt; mso-list: l9 level1 lfo48; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">f.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI;">Pertahankan
pemberian oksigen</span><span lang="EN-US"></span></div>
</td>
</tr>
</tbody></table>
</div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l2 level3 lfo15; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">N.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Implementasi </span></b><b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">dan Evaluasi</span><span lang="EN-US"></span></b></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Implementasi </span><span lang="EN-US">Hari Pertama
Tanggal<span style="mso-spacerun: yes;"> </span>30 Mei 2013</span></b><b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;"></span></b></div>
<table border="1" cellpadding="0" cellspacing="0" class="LightList1" style="border-collapse: collapse; border: none; mso-border-alt: solid windowtext .5pt; mso-border-insideh: .5pt solid windowtext; mso-border-insidev: .5pt solid windowtext; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-yfti-tbllook: 1184; width: 971px;">
<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: -1;">
<td style="background: #BFBFBF; border: solid windowtext 1.0pt; mso-background-themecolor: background1; mso-background-themeshade: 191; mso-border-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.3pt;" valign="top" width="35">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 5; text-align: center;">
<b><span lang="EN-US">No</span></b></div>
</td>
<td style="background: #BFBFBF; border-left: none; border: solid windowtext 1.0pt; mso-background-themecolor: background1; mso-background-themeshade: 191; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 131.55pt;" valign="top" width="175">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 1; text-align: center;">
<b><span lang="EN-US">Diagnosa Keperawatan</span></b></div>
</td>
<td style="background: #BFBFBF; border-left: none; border: solid windowtext 1.0pt; mso-background-themecolor: background1; mso-background-themeshade: 191; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 216.1pt;" valign="top" width="288">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 1; text-align: center;">
<b><span lang="EN-US">Implementasi Keperawatan</span></b></div>
</td>
<td style="background: #BFBFBF; border-left: none; border: solid windowtext 1.0pt; mso-background-themecolor: background1; mso-background-themeshade: 191; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 241.0pt;" valign="top" width="321">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 1; text-align: center;">
<b><span lang="EN-US">Evaluasi Keperawatan</span></b></div>
</td>
<td style="background: #BFBFBF; border-left: none; border: solid windowtext 1.0pt; mso-background-themecolor: background1; mso-background-themeshade: 191; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 4.0cm;" valign="top" width="151">
<div align="left" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 1; tab-stops: 39.75pt center 53.75pt; text-align: left;">
<b><span style="mso-ansi-language: IN;"><span style="mso-tab-count: 2;"> </span>TTD</span></b></div>
</td>
</tr>
<tr style="mso-yfti-irow: 0;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-left-themecolor: text1; mso-border-right-alt: solid windowtext .5pt; mso-border-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.3pt;" valign="top" width="35">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 68; text-align: center;">
<span lang="EN-US" style="mso-bidi-font-weight: bold;">1.</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 131.55pt;" valign="top" width="175">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span style="mso-ansi-language: IN;">Ketidakefektifan </span><span lang="EN-US">perfusi jaringan cerebral berhubungan dengan gangguan aliran
arteri atau vena</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 216.1pt;" valign="top" width="288">
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; mso-list: l124 level1 lfo74; mso-yfti-cnfc: 64; text-align: left; text-indent: -18.0pt;">
<span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI;">Memonitor
TTV ( Perjam, 11.00 – 14.00)</span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; mso-list: l124 level1 lfo74; mso-yfti-cnfc: 64; text-align: left; text-indent: -18.0pt;">
<span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI;">Memonitor
SPO<sub>2</sub>, ukuran pupil, , kesimetrisan dan reaksi</span><span lang="SV" style="mso-ansi-language: SV;">. ( jam 13.45)</span><span lang="FI" style="mso-ansi-language: FI;"></span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; mso-list: l124 level1 lfo74; mso-yfti-cnfc: 64; text-align: left; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Mencatat
perubahan pasien dalam merespon stimulus. (jam 13.45)</span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; mso-list: l124 level1 lfo74; mso-yfti-cnfc: 64; text-align: left; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Memonitor
status cairan (jam 13.00).</span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; mso-list: l124 level1 lfo74; mso-yfti-cnfc: 64; text-align: left; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Memantau
tingkat kesadaran pasien. ( 13.45).</span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; mso-list: l124 level1 lfo74; mso-yfti-cnfc: 64; text-align: left; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Kolaborasi
dalam pemberian</span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt; mso-list: l124 level2 lfo74; mso-yfti-cnfc: 64; text-align: left; text-indent: -9.0pt;">
<span lang="SV" style="font-family: Symbol; mso-ansi-language: SV; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Oksigenasi
( Nassa Kanul, 3 Lpm).</span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt; mso-list: l124 level2 lfo74; mso-yfti-cnfc: 64; text-align: left; text-indent: -9.0pt;">
<span lang="SV" style="font-family: Symbol; mso-ansi-language: SV; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Farmakologi
: </span><span lang="EN-US">Brainact 500mg</span><span lang="SV" style="mso-ansi-language: SV;">, </span><span lang="EN-US">Farbion drip 1ampul 3
ml</span><span lang="SV" style="mso-ansi-language: SV;">, Ranitidine 50 mg dan </span><span lang="EN-US">Methylprednisolone 125mg.</span><span lang="SV" style="mso-ansi-language: SV;"></span></div>
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<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 241.0pt;" valign="top" width="321">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">S = -</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">O =</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Vital Sign tiap jam terlampir</span><span style="mso-ansi-language: IN;"> pada catatan perkembangan RM12 </span><span lang="SV" style="mso-ansi-language: SV;">( jam 1</span><span style="mso-ansi-language: IN;">1.00-21.00</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pupil isokor ukuran 2 : 2
reaksi +/+</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam 13.45)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Input IVFD Futrolit 100 ml</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam 13.</span><span style="mso-ansi-language: IN;">30</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Output Urine = 100 ml</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam 13</span><span style="mso-ansi-language: IN;">.30</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">O<sub>2</sub> 3 liter/menit</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam 1</span><span style="mso-ansi-language: IN;">2.00</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Kesadaran Sopor <span style="mso-spacerun: yes;"> </span>GCS E2, V2, M2</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam 13.45)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Therapy farmakologi telah
dilaksanakan sesuai advice dokter.</span><span lang="EN-US" style="mso-ansi-language: SV;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">18.00</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">A =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Masalah belum teratasi</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">P =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Lanjutkan intervensi</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l70 level1 lfo72; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pantau vital sign</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l70 level1 lfo72; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Monitoring SPO<sub>2</sub> ,
ukuran pupil, kesimetrisan, dan reaksi.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l70 level1 lfo72; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Monitor status cairan</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l70 level1 lfo72; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pantau perubahan tingkat
kesadaran pasien.</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-right-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 4.0cm;" valign="top" width="151">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: center;">
<span lang="EN-US">Siti Suwarsih S,Kep</span><span style="mso-ansi-language: IN;"></span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: center;">
<span style="mso-ansi-language: IN;">&</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: center;">
<span lang="EN-US">Nurul Hidayah S,Kep</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 1;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.3pt;" valign="top" width="35">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 4; text-align: center;">
<span lang="EN-US" style="mso-bidi-font-weight: bold;">2</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 131.55pt;" valign="top" width="175">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Kelebihan volume cairan tubuh b.d gangguan mekanisme regulasi</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 216.1pt;" valign="top" width="288">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 17.65pt; mso-add-space: auto; mso-list: l41 level2 lfo47; text-align: justify; text-indent: -18.0pt;">
<span lang="FI" style="mso-ansi-language: FI; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI;">Monitor
balance cairan ( 13.00)</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 17.65pt; mso-add-space: auto; mso-list: l41 level2 lfo47; text-align: justify; text-indent: -18.0pt;">
<span lang="FI" style="mso-ansi-language: FI; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI;">Monitor
TTV (Perjam ( 07.00-14.00)</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 241.0pt;" valign="top" width="321">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">S=-</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">O= </span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 17.55pt; mso-add-space: auto; mso-list: l69 level2 lfo51; tab-stops: list 13.05pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Input futrolit 100 ml</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 17.55pt; mso-add-space: auto; mso-list: l69 level2 lfo51; tab-stops: list 13.05pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Urin 100ml</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam 1</span><span style="mso-ansi-language: IN;">1.00)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 17.55pt; mso-add-space: auto; mso-list: l69 level2 lfo51; tab-stops: list 13.05pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">TTV terlampir</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 17.55pt; mso-add-space: auto; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 4.05pt; mso-add-space: auto; text-align: justify;">
<span lang="EN-US">A= Masalah
teratasi sebagian</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 4.05pt; mso-add-space: auto; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 4.05pt; mso-add-space: auto; text-align: justify;">
<span lang="EN-US">P= Lanjutkan
intervensi</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 4.0cm;" valign="top" width="151">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="EN-US">Siti Suwarsih S,Kep</span><span style="mso-ansi-language: IN;"></span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">&</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="EN-US">Nurul Hidayah S,Kep</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 2;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-left-themecolor: text1; mso-border-right-alt: solid windowtext .5pt; mso-border-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.3pt;" valign="top" width="35">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 68; text-align: center;">
<span lang="EN-US" style="mso-bidi-font-weight: bold;">3.</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 131.55pt;" valign="top" width="175">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span style="mso-ansi-language: IN;">Ketidakefektifan </span><span lang="EN-US">perfusi jaringan cerebral berhubungan dengan gangguan aliran
arteri atau vena</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 216.1pt;" valign="top" width="288">
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 13.5pt; mso-list: l27 level1 lfo75; mso-yfti-cnfc: 64; text-align: left; text-indent: -13.5pt;">
<span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI;">Memonitor
TTV ( perjam, 14.00 – 21.00).</span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 13.5pt; mso-list: l27 level1 lfo75; mso-yfti-cnfc: 64; text-align: left; text-indent: -13.5pt;">
<span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI;">Memonitor
SPO<sub>2</sub>, ukuran pupil, , kesimetrisan dan reaksi</span><span lang="SV" style="mso-ansi-language: SV;">. </span><span lang="FI" style="mso-ansi-language: FI;">( perjam, 14.00 – 21.00).</span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 13.5pt; mso-list: l27 level1 lfo75; mso-yfti-cnfc: 64; text-align: left; text-indent: -13.5pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Mencatat
perubahan pasien dalam merespon stimulus. (jam 20.00)</span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 13.5pt; mso-list: l27 level1 lfo75; mso-yfti-cnfc: 64; text-align: left; text-indent: -13.5pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Memonitor
status cairan (jam 20.00)</span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 13.5pt; mso-list: l27 level1 lfo75; mso-yfti-cnfc: 64; text-align: left; text-indent: -13.5pt;">
<span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Memantau
tingkat kesadaran pasien.</span><span lang="FI" style="mso-ansi-language: FI;">(
perjam, 14.00 – 21.00).</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 241.0pt;" valign="top" width="321">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">S<span style="mso-spacerun: yes;"> </span>= -</span></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">O =</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Vital Sign tiap jam terlampir</span><span style="mso-ansi-language: IN;"> pada catatan perkembangan RM12</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pupil isokor ukuran 2 : 2
reaksi +/+</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Input </span><span style="mso-ansi-language: IN;">Asering dan diit</span> <span style="mso-ansi-language: IN;">65</span><span lang="EN-US">0 ml</span><span style="mso-ansi-language: IN;">
(16.00)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Output Urine = </span><span style="mso-ansi-language: IN;">3</span><span lang="EN-US">00 ml</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">20.30</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">O<sub>2</sub> 3 liter/menit</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">A =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Masalah belum teratasi</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">P =</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Lanjutkan
intervensi : </span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l102 level1 lfo73; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pantau vital sign</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l102 level1 lfo73; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Monitoring SPO<sub>2</sub> ,
ukuran pupil, kesimetrisan, dan reaksi.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l102 level1 lfo73; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Monitor status cairan</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l102 level1 lfo73; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pantau perubahan tingkat
kesadaran pasien.</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-right-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 4.0cm;" valign="top" width="151">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Prima Agustin W S,Kep</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 3;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.3pt;" valign="top" width="35">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 4; text-align: center;">
<span lang="EN-US" style="mso-bidi-font-weight: bold;">4</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 131.55pt;" valign="top" width="175">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Kelebihan volume cairan tubuh b.d gangguan mekanisme regulasi</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 216.1pt;" valign="top" width="288">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 17.65pt; mso-add-space: auto; text-align: justify;">
<span lang="FI" style="mso-ansi-language: FI;">Monitor balance cairan ( 20.00)</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 17.65pt; mso-add-space: auto; text-align: justify;">
<span lang="FI" style="mso-ansi-language: FI;">Monitor TTV (Perjam (14.00-21.00)</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 241.0pt;" valign="top" width="321">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">S=-</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">O= </span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 17.55pt; mso-add-space: auto; mso-list: l69 level2 lfo51; tab-stops: list 13.05pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Input futrolit </span><span style="mso-ansi-language: IN;">dan diit 2</span><span lang="EN-US">00 ml</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">20.30</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 17.55pt; mso-add-space: auto; mso-list: l69 level2 lfo51; tab-stops: list 13.05pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Urin </span><span style="mso-ansi-language: IN;">100</span><span lang="EN-US"> ml</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">20.45</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 17.55pt; mso-add-space: auto; mso-list: l69 level2 lfo51; tab-stops: list 13.05pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Balance cairan </span><span style="mso-ansi-language: IN;">+ 100</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 17.55pt; mso-add-space: auto; mso-list: l69 level2 lfo51; tab-stops: list 13.05pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">TTV terlampir</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 4.05pt; mso-add-space: auto; text-align: justify;">
<span lang="EN-US">A= Masalah
teratasi sebagian</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 4.05pt; mso-add-space: auto; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 4.05pt; mso-add-space: auto; text-align: justify;">
<span lang="EN-US">P= Lanjutkan
intervensi</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 4.0cm;" valign="top" width="151">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="EN-US">Prima Agustin W S,Kep</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 4;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-left-themecolor: text1; mso-border-right-alt: solid windowtext .5pt; mso-border-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.3pt;" valign="top" width="35">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 68; text-align: center;">
<span lang="EN-US" style="mso-bidi-font-weight: bold;">5</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 131.55pt;" valign="top" width="175">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Hambatan Mobilitas Fisik</span><span style="mso-ansi-language: IN;"> b</span><span lang="EN-US">erhubungan dengan kaku sendi atau kontraktur</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 216.1pt;" valign="top" width="288">
<div class="MsoNormal" style="line-height: 150%; margin-left: 9.0pt; mso-list: l18 level1 lfo76; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.5pt;">
<span lang="NL" style="mso-ansi-language: NL;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="mso-ansi-language: NL;">Memonitor respon kardiovaskuler<span style="mso-spacerun: yes;"> </span>terhadap aktivitas (takikardi, disritmia,
sesak nafas, diaporesis, pucat, perubahan hemodinamik). (perjam,
14.00-21.00).</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 9.0pt; mso-list: l18 level1 lfo76; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.5pt;">
<span lang="NL" style="mso-ansi-language: NL;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="mso-ansi-language: NL;">Memantau perkembangan motorik pasien.
(15.00)</span></div>
<div class="MsoBodyTextIndent2" style="margin-left: 9.0pt; mso-list: l18 level1 lfo76; mso-yfti-cnfc: 64; text-indent: -13.5pt;">
<span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Memantau respon oksigen pasien terhadap
aktivitas keperawatan.</span><span lang="NL" style="mso-ansi-language: NL;">
(perjam, 14.00-21.00)</span><span lang="FI" style="mso-ansi-language: FI;"></span></div>
<div class="MsoBodyTextIndent2" style="margin-left: 9.0pt; mso-list: l18 level1 lfo76; mso-yfti-cnfc: 64; text-indent: -13.5pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI;">Mempertahankan
pemberian oksigen. </span><span lang="NL" style="mso-ansi-language: NL;">(perjam,
14.00-21.00)</span><span lang="EN-US"></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 241.0pt;" valign="top" width="321">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">S= -</span></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">O =</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 22.95pt; mso-add-space: auto; mso-list: l92 level1 lfo54; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Tidak ada Tachikardia dan
sesak nafas.</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">15.00</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 22.95pt; mso-add-space: auto; mso-list: l92 level1 lfo54; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">O<sub>2</sub> nassa kanul 3
liter/menit.</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 22.95pt; mso-add-space: auto; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">A =</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="EN-US">Masalah teratasi
sebagian</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">P =</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="EN-US">Lanjutkan Intervensi</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l3 level1 lfo77; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.5pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Monitor respon kardiovaskuler
terhadap aktifitas.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l3 level1 lfo77; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.5pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pantau perkembangan motorik
pasien.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l3 level1 lfo77; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.5pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pantau respon oksigen pasien
terhadap aktifitas keperwatan.</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l3 level1 lfo77; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.5pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pertahankan pemberian oksigen.</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-right-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 4.0cm;" valign="top" width="151">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Prima Agustin W S,Kep</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 5;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.3pt;" valign="top" width="35">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 4; text-align: center;">
<span lang="EN-US" style="mso-bidi-font-weight: bold;">6</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 131.55pt;" valign="top" width="175">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Defisit perawatn diri total berhubungan dengan intoleransi
aktivitas</span><span style="mso-ansi-language: IN;"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 216.1pt;" valign="top" width="288">
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l33 level1 lfo52; tab-stops: list 36.0pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Memonitor kemampuan klien untuk
perawatan diri yang mandiri. ( Jam 14.50)</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l33 level1 lfo52; tab-stops: list 36.0pt; text-align: justify; text-indent: -14.2pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Memonitor dan membantu kebutuhan klien untuk alat-alat bantu untuk
kebersihan diri, berpakaian, berhias, toileting dan makan. (15.00)</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l33 level1 lfo52; tab-stops: list 36.0pt; text-align: justify; text-indent: -14.2pt;">
<span lang="EN-US" style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Membantu sampai klien mampu secara utuh untuk melakukan
self-care.(15.00)</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 241.0pt;" valign="top" width="321">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">S = -</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">O =</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l21 level1 lfo55; text-align: justify; text-indent: -14.2pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Pasien mengalami penurunan kesadaran</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l21 level1 lfo55; text-align: justify; text-indent: -14.2pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Pasien tampak bersih dan wangi setelah dilakukan personal hygiene.</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">15.30</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l21 level1 lfo55; text-align: justify; text-indent: -14.2pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Pasien tampak belum bisa melakukan self care secara mandiri</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">16.00</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; text-align: justify;">
<span lang="EN-US">A =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; text-align: justify;">
<span lang="EN-US">Masalah teratasi sebagian</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; text-align: justify;">
<span lang="EN-US">P =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; text-align: justify;">
<span lang="EN-US">Lanjutkan Intervensi.</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-left: 15.6pt; mso-add-space: auto; mso-list: l76 level1 lfo78; text-align: justify; text-indent: -11.4pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Bantu pasien dalam melakukan self care.</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 4.0cm;" valign="top" width="151">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Prima Agustin W S,Kep</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 6;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-left-themecolor: text1; mso-border-right-alt: solid windowtext .5pt; mso-border-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.3pt;" valign="top" width="35">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 68; text-align: center;">
<span lang="EN-US" style="mso-bidi-font-weight: bold;">7</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 131.55pt;" valign="top" width="175">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span style="mso-ansi-language: IN;">Ketidakefektifan </span><span lang="EN-US">perfusi jaringan cerebral berhubungan dengan gangguan aliran
arteri atau vena</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 216.1pt;" valign="top" width="288">
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 13.5pt; mso-list: l8 level1 lfo79; mso-yfti-cnfc: 64; text-align: left; text-indent: -13.5pt;">
<span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI;">Memonitor
TTV ( perjam, 21.00 – 07.00).</span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 13.5pt; mso-list: l8 level1 lfo79; mso-yfti-cnfc: 64; text-align: left; text-indent: -13.5pt;">
<span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI;">Memonitor
SPO<sub>2</sub>, ukuran pupil, , kesimetrisan dan reaksi</span><span lang="SV" style="mso-ansi-language: SV;">, dan tingkat kesadaran pasien( jam 07.00)</span><span lang="FI" style="mso-ansi-language: FI;"></span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 13.5pt; mso-list: l8 level1 lfo79; mso-yfti-cnfc: 64; text-align: left; text-indent: -13.5pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Mencatat
perubahan pasien dalam merespon stimulus. (05.00)</span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 13.5pt; mso-list: l8 level1 lfo79; mso-yfti-cnfc: 64; text-align: left; text-indent: -13.5pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Memonitor
status cairan (06.00)</span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 13.5pt; mso-list: l8 level1 lfo79; mso-yfti-cnfc: 64; text-align: left; text-indent: -13.5pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Memantau
tingkat kesadaran pasien. (07.00)</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 241.0pt;" valign="top" width="321">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">S =<span style="mso-spacerun: yes;"> </span>-</span></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">O =</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Vital sign perjam terlampir</span><span style="mso-ansi-language: IN;"> pada catatan perkembangan RM12</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pupil isokor ukuran 2 : 2
reaksi +/+</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Input IVFD Futrolit </span><span style="mso-ansi-language: IN;">dan diit 1200</span><span lang="EN-US"> ml </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">06.00</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Output Urine = </span><span style="mso-ansi-language: IN;">1650</span><span lang="EN-US"> ml</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">06.30</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="SV" style="mso-ansi-language: IN;"> </span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Cairan Balance </span><span style="mso-ansi-language: IN;">24 jam -45</span><span lang="EN-US">0 ml</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">07.00</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">O<sub>2</sub> 3 liter/menit</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Kesadaran Sopor <span style="mso-spacerun: yes;"> </span>GCS E2, V2, M2</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">07.30</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">A =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Masalah teratasi sebagian</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">P =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Lanjutkan intervensi</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l72 level1 lfo80; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pantau vital sign</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l72 level1 lfo80; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Monitoring SPO<sub>2</sub> ,
ukuran pupil, kesimetrisan, dan reaksi.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l72 level1 lfo80; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Monitor status cairan.</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l72 level1 lfo80; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pantau perubahan tingkat
kesadaran pasien.</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-right-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 4.0cm;" valign="top" width="151">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Erfansyah S,Kep</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 7;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.3pt;" valign="top" width="35">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 4; text-align: center;">
<span lang="EN-US" style="mso-bidi-font-weight: bold;">8</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 131.55pt;" valign="top" width="175">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Hambatan Mobilitas Fisik</span><span style="mso-ansi-language: IN;"> b</span><span lang="EN-US">erhubungan dengan kontraktur.</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 216.1pt;" valign="top" width="288">
<div class="MsoNormal" style="line-height: 150%; margin-left: 22.95pt; mso-list: l121 level1 lfo56; text-align: justify; text-indent: -18.0pt;">
<span lang="IT" style="mso-ansi-language: IT;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="mso-ansi-language: NL;">Memonitor respon kardiovaskuler<span style="mso-spacerun: yes;"> </span>terhadap aktivitas (takikardi, disritmia,
sesak nafas, diaporesis, pucat, perubahan hemodinamik). (05.00)</span><span lang="IT" style="mso-ansi-language: IT;"></span></div>
<div class="MsoBodyTextIndent2" style="margin-left: 22.95pt; mso-list: l121 level1 lfo56; text-indent: -18.0pt;">
<span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Memantau respon oksigen pasien terhadap
aktivitas keperawatan (05.00)</span></div>
<div class="MsoBodyTextIndent2" style="margin-left: 22.95pt; mso-list: l121 level1 lfo56; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI;">Mempertahankan
pemberian oksigen. (perjam 21.0 – 07.00)</span><span lang="EN-US"></span></div>
<div class="MsoBodyTextIndent2" style="margin-left: 22.95pt; mso-list: l121 level1 lfo56; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI;">Memantau
kemampuasn pasien mobilisasi di tempat tidur. (05.00 – 07.00).</span><span lang="EN-US"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 241.0pt;" valign="top" width="321">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">S= -</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">O =</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Vital sign perjam terlampir</span><span style="mso-ansi-language: IN;"> pada catatan perkembangan RM12</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l92 level1 lfo54; text-align: justify; text-indent: -14.2pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Tidak ada Tachikardia dan sesak nafas.</span><span lang="SV" style="mso-ansi-language: SV;"> ( jam </span><span style="mso-ansi-language: IN;">05.10</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l92 level1 lfo54; text-align: justify; text-indent: -14.2pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">O<sub>2</sub> nassa kanul 3 liter/menit.</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l92 level1 lfo54; text-align: justify; text-indent: -14.2pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Pasien tampak bedrest ditempat tidur, hanya bisa menggerakkan
anggota tubuh sebelah kiri</span><span style="mso-ansi-language: IN;">. </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">07.30</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; text-align: justify;">
<span lang="EN-US">A =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; text-align: justify;">
<span lang="EN-US">Masalah teratasi sebagian</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; text-align: justify;">
<span lang="EN-US">P =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; text-align: justify;">
<span lang="EN-US">Lanjutkan Intervensi.</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.6pt; mso-add-space: auto; mso-list: l35 level1 lfo81; text-align: justify; text-indent: -11.85pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pantau respon kardiovaskuler.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.6pt; mso-add-space: auto; mso-list: l35 level1 lfo81; text-align: justify; text-indent: -11.85pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pantau respon oksigen tehadap aktifitas keperawatan.</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 15.6pt; mso-add-space: auto; mso-list: l35 level1 lfo81; text-align: justify; text-indent: -11.85pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pantau kemampuan mobilisasi pasien</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 4.0cm;" valign="top" width="151">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Erfansyah S,Kep</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 8; mso-yfti-lastrow: yes;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-left-themecolor: text1; mso-border-right-alt: solid windowtext .5pt; mso-border-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.3pt;" valign="top" width="35">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 68; text-align: center;">
<span lang="EN-US" style="mso-bidi-font-weight: bold;">9</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 131.55pt;" valign="top" width="175">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Defisit perawat</span><span style="mso-ansi-language: IN;">a</span><span lang="EN-US">n diri total berhubungan dengan intoleransi
aktivitas</span><span style="mso-ansi-language: IN;"></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 216.1pt;" valign="top" width="288">
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l15 level1 lfo57; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Memonitor kemampuan klien untuk
perawatan diri yang mandiri.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l15 level1 lfo57; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Memonitor dan membantu
kebutuhan klien untuk alat-alat bantu untuk kebersihan diri, berpakaian,
berhias, toileting dan makan.</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">04.30</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l15 level1 lfo57; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Membantu sampai klien mampu
secara utuh untuk melakukan self-care.</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">04.50</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 241.0pt;" valign="top" width="321">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">S = -</span></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">O =</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l21 level1 lfo55; mso-yfti-cnfc: 64; text-align: justify; text-indent: -14.2pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pasien mengalami penurunan
kesadaran. Dengan tingkat kesadaran somnolent</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">04.00</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l21 level1 lfo55; mso-yfti-cnfc: 64; text-align: justify; text-indent: -14.2pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pasien tampak bersih dan
wangi setelah dilakukan personal hygiene</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam</span><span style="mso-ansi-language: IN;"> 04.45</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l21 level1 lfo55; mso-yfti-cnfc: 64; text-align: justify; text-indent: -14.2pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pasien tampak belum bisa melakukan
self care secara mandiri</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">05.0</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">A =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Masalah teratasi sebagian</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">P =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Lanjutkan Intervensi</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-right-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 4.0cm;" valign="top" width="151">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Erfansyah S,Kep</span></div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Implementasi hari Kedua tanggal 31 Mei 2013</span></b><b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;"></span></b></div>
<table border="1" cellpadding="0" cellspacing="0" class="LightList1" style="border-collapse: collapse; border: none; mso-border-alt: solid windowtext .5pt; mso-border-insideh: .5pt solid windowtext; mso-border-insidev: .5pt solid windowtext; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-yfti-tbllook: 1184; width: 971px;">
<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: -1;">
<td style="background: #D99594; border: solid windowtext 1.0pt; mso-background-themecolor: accent2; mso-background-themetint: 153; mso-border-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.25pt;" valign="top" width="35">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 5; text-align: center;">
<b><span lang="EN-US">No</span></b></div>
</td>
<td style="background: #D99594; border-left: none; border: solid windowtext 1.0pt; mso-background-themecolor: accent2; mso-background-themetint: 153; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 131.55pt;" valign="top" width="175">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 1; text-align: center;">
<b><span lang="EN-US">Diagnosa Keperawatan</span></b></div>
</td>
<td style="background: #D99594; border-left: none; border: solid windowtext 1.0pt; mso-background-themecolor: accent2; mso-background-themetint: 153; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 216.15pt;" valign="top" width="288">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 1; text-align: center;">
<b><span lang="EN-US">Implementasi Keperawatan</span></b></div>
</td>
<td style="background: #D99594; border-left: none; border: solid windowtext 1.0pt; mso-background-themecolor: accent2; mso-background-themetint: 153; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 241.0pt;" valign="top" width="321">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 1; text-align: center;">
<b><span lang="EN-US">Evaluasi Keperawatan</span></b></div>
</td>
<td style="background: #D99594; border-left: none; border: solid windowtext 1.0pt; mso-background-themecolor: accent2; mso-background-themetint: 153; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 4.0cm;" valign="top" width="151">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 1; text-align: center;">
<b><span lang="EN-US">TTD</span></b></div>
</td>
</tr>
<tr style="mso-yfti-irow: 0;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-left-themecolor: text1; mso-border-right-alt: solid windowtext .5pt; mso-border-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.25pt;" valign="top" width="35">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 68; text-align: center;">
<span lang="EN-US" style="mso-bidi-font-weight: bold;">1.</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 131.55pt;" valign="top" width="175">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span style="mso-ansi-language: IN;">Ketidakefektifan </span><span lang="EN-US">perfusi jaringan cerebral berhubungan dengan gangguan aliran
arteri atau vena</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 216.15pt;" valign="top" width="288">
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; mso-list: l34 level1 lfo84; mso-yfti-cnfc: 64; text-align: left; text-indent: -18.0pt;">
<span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI;">Memonitor
TTV ( perjam, 08.00 – 07.00).</span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; mso-list: l34 level1 lfo84; mso-yfti-cnfc: 64; text-align: left; text-indent: -18.0pt;">
<span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI;">Memonitor
SPO<sub>2</sub>, ukuran pupil, , kesimetrisan dan reaksi</span><span lang="SV" style="mso-ansi-language: SV;">, ( jam 13.40)</span><span lang="FI" style="mso-ansi-language: FI;"></span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; mso-list: l34 level1 lfo84; mso-yfti-cnfc: 64; text-align: left; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Mencatat
perubahan pasien dalam merespon stimulus. (13.40)</span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; mso-list: l34 level1 lfo84; mso-yfti-cnfc: 64; text-align: left; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Memonitor
status cairan (13..00)</span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; mso-list: l34 level1 lfo84; mso-yfti-cnfc: 64; text-align: left; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Memantau
tingkat kesadaran pasien. (07.00)</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 241.0pt;" valign="top" width="321">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">S = -</span></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">O =</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Vital Sign perjam terlampir</span><span style="mso-ansi-language: IN;"> pada catatan perkembangan RM12</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pupil isokor ukuran 2 : 2
reaksi +/+</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Input IVFD</span><span style="mso-ansi-language: IN;"> Futrolit</span> <span style="mso-ansi-language: IN;">550 </span><span lang="EN-US">ml</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam 13.45)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Output Urine = 1</span><span style="mso-ansi-language: IN;">5</span><span lang="EN-US">0 ml</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam 13.45)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Balance + </span><span style="mso-ansi-language: IN;">4</span><span lang="EN-US">00</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam 13.45)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">O<sub>2</sub> 3 liter/menit</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Kesadaran Somnolen GCS </span><span style="mso-ansi-language: IN;">E</span><span lang="EN-US">3, V2, M2</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">A =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Masalah belum teratasi</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">P =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Lanjutkan intervensi</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l44 level1 lfo82; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pantau vital sign</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l44 level1 lfo82; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Monitoring SPO<sub>2</sub> ,
ukuran pupil, kesimetrisan, dan reaksi.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l44 level1 lfo82; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Monitor status cairan.</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l44 level1 lfo82; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pantau perubahan tingkat
kesadaran pasien.</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-right-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 4.0cm;" valign="top" width="151">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: center;">
<span lang="EN-US">Siti<span style="mso-spacerun: yes;">
</span>Suwarsih S.Kep</span><span style="mso-ansi-language: IN;"></span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: center;">
<span style="mso-ansi-language: IN;">&</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: center;">
<span lang="EN-US">Prima Agustin W S,Kep</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 1;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.25pt;" valign="top" width="35">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 4; text-align: center;">
<span lang="EN-US" style="mso-bidi-font-weight: bold;">2</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 131.55pt;" valign="top" width="175">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Kelebihan volume cairan tubuh b.d gangguan mekanisme regulasi</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 216.15pt;" valign="top" width="288">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 17.65pt; mso-add-space: auto; mso-list: l41 level2 lfo47; text-align: justify; text-indent: -18.0pt;">
<span lang="FI" style="mso-ansi-language: FI; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI;">Monitor
balance cairan ( 13.00)</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 17.65pt; mso-add-space: auto; mso-list: l41 level2 lfo47; text-align: justify; text-indent: -18.0pt;">
<span lang="FI" style="mso-ansi-language: FI; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI;">Monitor
TTV (Perjam ( 07.00-14.00)</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 241.0pt;" valign="top" width="321">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">S=-</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">O= </span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 17.55pt; mso-add-space: auto; mso-list: l69 level2 lfo51; tab-stops: list 13.05pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Input futrolit 200 ml</span><span style="mso-ansi-language: IN;"><span style="mso-spacerun: yes;"> </span></span><span lang="SV" style="mso-ansi-language: SV;">( jam 13.45)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 17.55pt; mso-add-space: auto; mso-list: l69 level2 lfo51; tab-stops: list 13.05pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Urin 1</span><span style="mso-ansi-language: IN;">5</span><span lang="EN-US">0</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="EN-US">ml</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam 13.45)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 17.55pt; mso-add-space: auto; mso-list: l69 level2 lfo51; tab-stops: list 13.05pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">TTV terlampir</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 17.55pt; mso-add-space: auto; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 4.05pt; mso-add-space: auto; text-align: justify;">
<span lang="EN-US">A= Masalah
teratasi sebagian</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 4.05pt; mso-add-space: auto; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 4.05pt; mso-add-space: auto; text-align: justify;">
<span lang="EN-US">P= Lanjutkan
intervensi</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 4.0cm;" valign="top" width="151">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="EN-US">Siti Suwarsih S,Kep</span><span style="mso-ansi-language: IN;"></span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">&</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="EN-US">Prima Agustin W S,Kep</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 2;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-left-themecolor: text1; mso-border-right-alt: solid windowtext .5pt; mso-border-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.25pt;" valign="top" width="35">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 68; text-align: center;">
<span lang="EN-US" style="mso-bidi-font-weight: bold;">3</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 131.55pt;" valign="top" width="175">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Defisit perawatn diri total berhubungan dengan
intoleransi aktivitas</span><span style="mso-ansi-language: IN;"></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 216.15pt;" valign="top" width="288">
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l84 level1 lfo58; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Melakukan
oral hygiene (07.45)</span><span lang="EN-US"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 241.0pt;" valign="top" width="321">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">S = -</span><span style="mso-ansi-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">O =</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l21 level1 lfo55; mso-yfti-cnfc: 64; text-align: justify; text-indent: -14.2pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pasien tampak bersih pada
baian mulut setelah dilakukan oral; hygiene</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">08</span><span lang="SV" style="mso-ansi-language: SV;">.</span><span style="mso-ansi-language: IN;">00</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l21 level1 lfo55; mso-yfti-cnfc: 64; text-align: justify; text-indent: -14.2pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pasien tampak belum bisa melakukan
self care secara mandiri</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">09.00</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">A =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Masalah teratasi sebagian</span></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">P =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Lanjutkan Intervensi.</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l29 level1 lfo83; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Bantu pasien dalam pemenuhan ADL
dan self care</span></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-right-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 4.0cm;" valign="top" width="151">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Siti<span style="mso-spacerun: yes;"> </span>Suwarsih
S.Kep</span></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">&</span></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Prima Agustin W S,Kep</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 3;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.25pt;" valign="top" width="35">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 4; text-align: center;">
<span lang="EN-US" style="mso-bidi-font-weight: bold;">4..</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 131.55pt;" valign="top" width="175">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: IN;">Ketidakefektifan </span><span lang="EN-US">perfusi
jaringan cerebral berhubungan dengan gangguan aliran arteri atau vena</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 216.15pt;" valign="top" width="288">
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; mso-list: l10 level1 lfo85; text-align: left; text-indent: -18.0pt;">
<span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Memonitor TTV ( perjam, 14.00 – 21.00).</span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; mso-list: l10 level1 lfo85; text-align: left; text-indent: -18.0pt;">
<span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Memonitor SPO<sub>2</sub>, ukuran pupil,
, kesimetrisan dan reaksi</span><span lang="SV" style="mso-ansi-language: SV;">,
dan tingkat kesadaran pasien( jam 20.00)</span><span lang="FI" style="mso-ansi-language: FI;"></span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; mso-list: l10 level1 lfo85; text-align: left; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Mencatat perubahan pasien dalam merespon
stimulus. (20.45)</span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; mso-list: l10 level1 lfo85; text-align: left; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Memonitor status cairan (20.00)</span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; mso-list: l10 level1 lfo85; text-align: left; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Memantau tingkat kesadaran pasien.
(20.45)</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 241.0pt;" valign="top" width="321">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">S = -</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">O =</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Vital sign perjam terlampir</span><span style="mso-ansi-language: IN;"> pada catatan perkembangan RM12</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Pupil isokor ukuran 2 : 2 reaksi +/+</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">20.50</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Kekuatan otot eks. Atas ki/ ka = </span><span style="mso-ansi-language: IN;">1</span><span lang="EN-US">/1</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">20.50</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Kekuatan otot eks. Bawah ki/ka = </span><span style="mso-ansi-language: IN;">1</span><span lang="EN-US">/1</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">20.50</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="mso-ansi-language: IN;">Input </span><span style="mso-spacerun: yes;"> </span><span style="mso-ansi-language: IN;">Futrolit
+ diit diabetasol</span><span lang="EN-US"> = </span><span style="mso-ansi-language: IN;">8</span><span lang="EN-US">00 ml</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="mso-ansi-language: IN;">Output 350 </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">20.30</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Balance <span style="mso-spacerun: yes;"> </span></span><span style="mso-ansi-language: IN;">+ 45</span><span lang="EN-US">0 ml</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">20.50</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">O<sub>2</sub> 3 liter/menit</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; text-align: justify;">
<span lang="EN-US">A =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; text-align: justify;">
<span lang="EN-US">Masalah teratasi sebagian</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; text-align: justify;">
<span lang="EN-US">P =</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Lanjutkan intervensi.</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.6pt; mso-add-space: auto; mso-list: l125 level1 lfo86; text-align: justify; text-indent: -11.4pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pantau vital sign</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.6pt; mso-add-space: auto; mso-list: l125 level1 lfo86; text-align: justify; text-indent: -11.4pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Monitoring SPO<sub>2</sub> , ukuran pupil, kesimetrisan, dan
reaksi.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.6pt; mso-add-space: auto; mso-list: l125 level1 lfo86; text-align: justify; text-indent: -11.4pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Monitor status cairan.</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 15.6pt; mso-add-space: auto; mso-list: l125 level1 lfo86; text-align: justify; text-indent: -11.4pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pantau perubahan tingkat kesadaran pasien.</span><span lang="EN-US"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 4.0cm;" valign="top" width="151">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Erfansyah S,Kep</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 4;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-left-themecolor: text1; mso-border-right-alt: solid windowtext .5pt; mso-border-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.25pt;" valign="top" width="35">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 68; text-align: center;">
<span lang="EN-US" style="mso-bidi-font-weight: bold;">5</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 131.55pt;" valign="top" width="175">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Kelebihan volume cairan tubuh b.d gangguan mekanisme
regulasi</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 216.15pt;" valign="top" width="288">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 17.65pt; mso-add-space: auto; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="FI" style="mso-ansi-language: FI;">Monitor balance cairan ( 20.00)</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 17.65pt; mso-add-space: auto; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="FI" style="mso-ansi-language: FI;">Monitor TTV (Perjam (14.00-21.00)</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 241.0pt;" valign="top" width="321">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">S=-</span></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">O= </span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 17.55pt; mso-add-space: auto; mso-list: l69 level2 lfo51; mso-yfti-cnfc: 64; tab-stops: list 13.05pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Input futrolit 400 ml</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Urin 600 ml</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">20.50</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Balance cairan -200</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">20.50</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 17.55pt; mso-add-space: auto; mso-list: l69 level2 lfo51; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">TTV terlampir</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 4.05pt; mso-add-space: auto; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">A=
Masalah teratasi sebagian</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 4.05pt; mso-add-space: auto; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">P=
Lanjutkan intervensi</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-right-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 4.0cm;" valign="top" width="151">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: center;">
<span lang="EN-US">Erfansyah S,Kep</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 5;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.25pt;" valign="top" width="35">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 4; text-align: center;">
<span lang="EN-US" style="mso-bidi-font-weight: bold;">6.</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 131.55pt;" valign="top" width="175">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Hambatan mobilisasi berhubungan dengan kontraktur.</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 216.15pt;" valign="top" width="288">
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l47 level1 lfo59; text-align: justify; text-indent: -14.2pt;">
<span lang="NL" style="mso-ansi-language: NL;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="mso-ansi-language: NL;">Memonitor respon kardiovaskuler<span style="mso-spacerun: yes;"> </span>terhadap aktivitas (takikardi, disritmia, sesak
nafas, diaporesis, pucat, perubahan hemodinamik) (15.20)</span></div>
<div class="MsoBodyTextIndent2" style="margin-left: 15.9pt; mso-list: l47 level1 lfo59; text-indent: -14.2pt;">
<span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Memantau respon oksigen pasien terhadap
aktivitas keperawatan. (15.20).</span></div>
<div class="MsoBodyTextIndent2" style="margin-left: 15.9pt; mso-list: l47 level1 lfo59; text-indent: -14.2pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI;">Mempertahankan
pemberian oksigen (setiap jam)</span><span lang="EN-US"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 241.0pt;" valign="top" width="321">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">S= -</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">O =</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Vital Sign perjam terlampir</span><span style="mso-ansi-language: IN;"> pada catatan perkembangan RM12</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Tidak ada Tachikardia dan sesak nafas,</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">15.50</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">O<sub>2</sub> nassa kanul 3 liter/menit</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">15.50</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">A =</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Masalah teratasi sebagian</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; text-align: justify;">
<span lang="EN-US">P =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; text-align: justify;">
<span lang="EN-US">Lanjutkan Intervensi</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l67 level1 lfo87; text-align: justify; text-indent: -13.5pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pantau respon kardiovaskuler.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l67 level1 lfo87; text-align: justify; text-indent: -13.5pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pantau respon oksigen tehadap
aktifitas keperawatan.</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l67 level1 lfo87; text-align: justify; text-indent: -13.5pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pantau kemampuan mobilisasi pasien</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 4.0cm;" valign="top" width="151">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Erfansyah S,Kep</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 6;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-left-themecolor: text1; mso-border-right-alt: solid windowtext .5pt; mso-border-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.25pt;" valign="top" width="35">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 68; text-align: center;">
<span lang="EN-US" style="mso-bidi-font-weight: bold;">7.</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 131.55pt;" valign="top" width="175">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Defisit perawatan diri total berhubungan dengan
intoleransi aktivitas</span><span style="mso-ansi-language: IN;"></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 216.15pt;" valign="top" width="288">
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l73 level1 lfo60; mso-yfti-cnfc: 64; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Memonitor kemampuan klien untuk
perawatan diri yang mandiri.(jam 14.40)</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l73 level1 lfo60; mso-yfti-cnfc: 64; text-align: justify; text-indent: -14.2pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Memonitor dan membantu
kebutuhan klien untuk alat-alat bantu untuk kebersihan diri, berpakaian,
berhias, toileting dan makan. ( 15.00)</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l73 level1 lfo60; mso-yfti-cnfc: 64; text-align: justify; text-indent: -14.2pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Membantu sampai klien mampu
secara utuh untuk melakukan self-care.( 15.00)</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 241.0pt;" valign="top" width="321">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">S = -</span></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">O =</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pasien mengalami penurunan
kesadaran. Pasien tampak bersih dan wangi setelah dilakukan personal hygiene</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">15.50</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pasien tampak belum bisa melakukan
self care secara mandiri</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">15.50</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">A =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Masalah teratasi sebagian</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">P =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Lanjutkan Intervensi.</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l103 level1 lfo88; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Bantu pasien dalam pemenuhan ADL
dan self care.</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-right-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 4.0cm;" valign="top" width="151">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Erfansyah S,Kep</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 7;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.25pt;" valign="top" width="35">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 4; text-align: center;">
<span lang="EN-US" style="mso-bidi-font-weight: bold;">8.</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 131.55pt;" valign="top" width="175">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: IN;">Ketidakefektifan </span><span lang="EN-US">perfusi
jaringan cerebral berhubungan dengan gangguan aliran arteri atau vena</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 216.15pt;" valign="top" width="288">
<div class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; mso-list: l39 level1 lfo89; text-align: justify; text-indent: -18.0pt;">
<span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Memonitor TTV ( perjam, 21.00 – 07.00).</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; mso-list: l39 level1 lfo89; text-align: justify; text-indent: -18.0pt;">
<span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Memonitor SPO<sub>2</sub>, ukuran pupil,
, kesimetrisan dan reaksi</span><span lang="SV" style="mso-ansi-language: SV;">,
dan tingkat kesadaran pasien( jam 05.10)</span><span lang="FI" style="mso-ansi-language: FI;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; mso-list: l39 level1 lfo89; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Mencatat perubahan pasien dalam merespon
stimulus. (05.45)</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; mso-list: l39 level1 lfo89; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Memonitor status cairan (06.00)</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; mso-list: l39 level1 lfo89; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Memantau tingkat kesadaran pasien.
(05.45)</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 241.0pt;" valign="top" width="321">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">S = -</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">O =</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Vital Sign perjam terlampir</span><span style="mso-ansi-language: IN;"> pada catatan perkembangan RM12</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Suhu badan 36,9<sup>0</sup>C</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">05.50</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Pupil isokor ukuran 2 : 2 reaksi +/+</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Input </span><span style="mso-ansi-language: IN;">Futrolit + </span><span lang="EN-US">Diit </span><span style="mso-ansi-language: IN;">deabeta</span><span lang="EN-US">sol </span><span style="mso-ansi-language: IN;">1750</span><span lang="EN-US"> ml </span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Output Urine = </span><span style="mso-ansi-language: IN;">950</span><span lang="EN-US"> ml</span><span style="mso-ansi-language: IN;"><span style="mso-spacerun: yes;"> </span></span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">06.50</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Cairan Balance</span><span style="mso-ansi-language: IN;"> 24 jam </span><span lang="EN-US"><span style="mso-spacerun: yes;"> </span>+ </span><span style="mso-ansi-language: IN;">80</span><span lang="EN-US">0 ml</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">07.20</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">O<sub>2</sub> 3 liter/menit</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Kesadaran Somnolen GCS E3, V2, M2</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">07.30</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; text-align: justify;">
<span lang="EN-US">A =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; text-align: justify;">
<span lang="EN-US">Masalah belum teratasi</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; text-align: justify;">
<span lang="EN-US">P =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; text-align: justify;">
<span lang="EN-US">Lanjutkan intervensi</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l85 level1 lfo90; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pantau vital sign</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l85 level1 lfo90; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Monitoring SPO<sub>2</sub> ,
ukuran pupil, kesimetrisan, dan reaksi.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l85 level1 lfo90; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Kaji kekuatan otot</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l85 level1 lfo90; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Monitor status cairan.</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l85 level1 lfo90; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pantau perubahan tingkat
kesadaran pasien.</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 4.0cm;" valign="top" width="151">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Nurul Hidayah S.Kep</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 8;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-left-themecolor: text1; mso-border-right-alt: solid windowtext .5pt; mso-border-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.25pt;" valign="top" width="35">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 68; text-align: center;">
<span lang="EN-US" style="mso-bidi-font-weight: bold;">9.</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 131.55pt;" valign="top" width="175">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Hambatan moibilitas fisik berhubungan dengan kaku sendi
atau kontraktur.</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 216.15pt;" valign="top" width="288">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="NL" style="mso-ansi-language: NL;">Memonitor
respon kardiovaskuler<span style="mso-spacerun: yes;"> </span>terhadap
aktivitas (takikardi, disritmia, sesak nafas, diaporesis, pucat, perubahan
hemodinamik)</span><span lang="NL" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">16.50</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI;">Memantau
respon oksigen pasien terhadap aktivitas keperawatan</span><span lang="FI" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">18.50</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI;">Mempertahankan
pemberian oksigen</span><span lang="FI" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">18.50)</span><span lang="EN-US"></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 241.0pt;" valign="top" width="321">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">S= -</span></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">O =</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Vital Sign Perjam terlampir</span><span style="mso-ansi-language: IN;"> pada catatan perkembangan RM12</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Tidak ada Tachikardia dan
sesak nafas.</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">20.50</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">O<sub>2</sub> nassa kanul 3
liter/menit.</span><span lang="SV" style="mso-ansi-language: SV;"> ( jam </span><span style="mso-ansi-language: IN;">20.50</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">A =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Masalah teratasi sebagian</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">P =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Lanjutkan Intervensi</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 24.6pt; mso-add-space: auto; mso-list: l108 level1 lfo91; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pantau respon kardiovaskuler.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 24.6pt; mso-add-space: auto; mso-list: l108 level1 lfo91; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pantau respon oksigen tehadap
aktifitas keperawatan.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 24.6pt; mso-add-space: auto; mso-list: l108 level1 lfo91; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pantau kemampuan mobilisasi
pasien.</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 24.6pt; mso-add-space: auto; mso-list: l108 level1 lfo91; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Ajarkan latihan ROM pasif.</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-right-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 4.0cm;" valign="top" width="151">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Nurul Hidayah S.Kep</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 9;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.25pt;" valign="top" width="35">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 4; text-align: center;">
<span lang="EN-US" style="mso-bidi-font-weight: bold;">10.</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 131.55pt;" valign="top" width="175">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Defisit perawatn diri total berhubungan dengan intoleransi
aktivitas</span><span style="mso-ansi-language: IN;"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 216.15pt;" valign="top" width="288">
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l54 level1 lfo61; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Memonitor kemampuan klien untuk
perawatan diri yang mandiri. (05.00)</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l54 level1 lfo61; text-align: justify; text-indent: -14.2pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Memonitor dan membantu
kebutuhan klien untuk alat-alat bantu untuk kebersihan diri, berpakaian,
berhias, toileting dan makan.(05.05)</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l54 level1 lfo61; text-align: justify; text-indent: -14.2pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Membantu sampai klien mampu
secara utuh untuk melakukan self-care.(05.00)</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 241.0pt;" valign="top" width="321">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">S = -</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">O =</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Pasien tampak bersih dan wangi setelah dilakukan personal hygiene.</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">06.00</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Pasien tampak belum bisa melakukan self care secara mandiri.</span><span lang="SV" style="mso-ansi-language: SV;"> ( jam </span><span style="mso-ansi-language: IN;">06.510</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; text-align: justify;">
<span lang="EN-US">A =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; text-align: justify;">
<span lang="EN-US">Masalah teratasi sebagian</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; text-align: justify;">
<span lang="EN-US">P =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; text-align: justify;">
<span lang="EN-US">Lanjutkan Intervensi</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-left: 15.6pt; mso-add-space: auto; mso-list: l90 level1 lfo92; text-align: justify; text-indent: -13.5pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Bantu pasien dalam ADL dan self
care.</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 4.0cm;" valign="top" width="151">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: IN;">Erfansyah</span><span lang="EN-US"> S.Kep</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 10; mso-yfti-lastrow: yes;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-left-themecolor: text1; mso-border-right-alt: solid windowtext .5pt; mso-border-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.25pt;" valign="top" width="35">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 68; text-align: center;">
<span lang="EN-US" style="mso-bidi-font-weight: bold;">11.</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 131.55pt;" valign="top" width="175">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Ketidakseimbangan nutrisi kurang dari kebutuhan tubuh
berhubungan dengan penyakit kronis (stroke).</span><span style="mso-ansi-language: IN;"></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 216.15pt;" valign="top" width="288">
<div class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; mso-list: l36 level1 lfo93; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.5pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Memonitor turgor kulit</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="EN-US"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; mso-list: l36 level1 lfo93; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.5pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Memonitor mual dan muntah</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; mso-list: l36 level1 lfo93; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.5pt;">
<span lang="NL" style="mso-ansi-language: NL;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="mso-ansi-language: NL;">Memonitor pucat, kemerahan, dan
kekeringan jaringan konjungtiva</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; mso-list: l36 level1 lfo93; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.5pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Memonitor intake nutrisi</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; mso-list: l36 level1 lfo93; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.5pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Mengatur posisi semi fowler
atau fowler tinggi selama makan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 18.0pt; mso-list: l36 level1 lfo93; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.5pt;">
<span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Mempertahankan terapi IV line</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 241.0pt;" valign="top" width="321">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">S = -</span></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">O =</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Turgor kulit </span><span style="mso-ansi-language: IN;">buruk </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">20.50</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pasien terpasang NGT</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">20.50</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l14 level1 lfo62; mso-yfti-cnfc: 64; text-align: justify; text-indent: -14.2pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pemberian Makan melalui NGT</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l14 level1 lfo62; mso-yfti-cnfc: 64; text-align: justify; text-indent: -14.2pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Diit </span><span style="mso-ansi-language: IN;">diabetasol</span><span lang="EN-US"> 250 gram</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Muntah tidak ada.</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">( jam </span><span style="mso-ansi-language: IN;">20.50</span><span lang="SV" style="mso-ansi-language: SV;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">A =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Masalah Teratasi</span></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">P =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Intervensi </span><span style="mso-ansi-language: IN;">dilanjutkan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l99 level1 lfo132; mso-yfti-cnfc: 64; text-align: justify; text-indent: -14.2pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Memonitor intake nutrisi</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l99 level1 lfo132; mso-yfti-cnfc: 64; text-align: justify; text-indent: -14.2pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Mengatur posisi semi fowler
atau fowler tinggi selama makan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l99 level1 lfo132; mso-yfti-cnfc: 64; text-align: justify; text-indent: -14.2pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI;">Mempertahankan
terapi IV line</span><span lang="EN-US"></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-right-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 4.0cm;" valign="top" width="151">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Nurul Hidayah S.Kep</span></div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Implementasi Hari Ke Tiga Tanggal 1 Juni <span style="mso-spacerun: yes;"> </span>2013</span></b></div>
<table border="1" cellpadding="0" cellspacing="0" class="LightList1" style="border-collapse: collapse; border: none; mso-border-alt: solid windowtext .5pt; mso-border-insideh: .5pt solid windowtext; mso-border-insidev: .5pt solid windowtext; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-yfti-tbllook: 1184; width: 945px;">
<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: -1;">
<td style="background: #95B3D7; border: solid windowtext 1.0pt; mso-background-themecolor: accent1; mso-background-themetint: 153; mso-border-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.25pt;" valign="top" width="35">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 5; text-align: center;">
<b><span lang="EN-US">No</span></b></div>
</td>
<td style="background: #95B3D7; border-left: none; border: solid windowtext 1.0pt; mso-background-themecolor: accent1; mso-background-themetint: 153; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 135.15pt;" valign="top" width="180">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 1; text-align: center;">
<b><span lang="EN-US">Diagnosa Keperawatan</span></b></div>
</td>
<td style="background: #95B3D7; border-left: none; border: solid windowtext 1.0pt; mso-background-themecolor: accent1; mso-background-themetint: 153; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 163.0pt;" valign="top" width="217">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 1; text-align: center;">
<b><span lang="EN-US">Implementasi Keperawatan</span></b></div>
</td>
<td style="background: #95B3D7; border-left: none; border: solid windowtext 1.0pt; mso-background-themecolor: accent1; mso-background-themetint: 153; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 219.65pt;" valign="top" width="293">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 1; text-align: center;">
<b><span lang="EN-US">Evaluasi Keperawatan</span></b></div>
</td>
<td style="background: #95B3D7; border-left: none; border: solid windowtext 1.0pt; mso-background-themecolor: accent1; mso-background-themetint: 153; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 164.7pt;" valign="top" width="220">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 1; text-align: center;">
<b><span lang="EN-US">TTD</span></b></div>
</td>
</tr>
<tr style="mso-yfti-irow: 0;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-left-themecolor: text1; mso-border-right-alt: solid windowtext .5pt; mso-border-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.25pt;" valign="top" width="35">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 68; text-align: justify;">
<b><span lang="EN-US">1.</span></b></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 135.15pt;" valign="top" width="180">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span style="mso-ansi-language: IN;">Ketidakefektifan </span><span lang="EN-US">perfusi jaringan cerebral berhubungan dengan gangguan aliran
arteri atau vena</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 163.0pt;" valign="top" width="217">
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l25 level1 lfo63; mso-yfti-cnfc: 64; text-align: left; text-indent: -14.2pt;">
<span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI;">Memonitor
TTV(perjam<span style="mso-spacerun: yes;"> </span>08.00 – 14.00)</span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l25 level1 lfo63; mso-yfti-cnfc: 64; text-align: left; text-indent: -14.2pt;">
<span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI;">Memonitor
SPO<sub>2</sub>, ukuran pupil, , kesimetrisan dan reaksi (13.45)</span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l25 level1 lfo63; mso-yfti-cnfc: 64; text-align: left; text-indent: -14.2pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Memonitor
tonus otot pergerakan. (10.20)</span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l25 level1 lfo63; mso-yfti-cnfc: 64; text-align: left; text-indent: -14.2pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Catat
perubahan pasien dalam merespon stimulus(13.45).</span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l25 level1 lfo63; mso-yfti-cnfc: 64; text-align: left; text-indent: -14.2pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">e.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Memonitor
status cairan(13.00)</span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l25 level1 lfo63; mso-yfti-cnfc: 64; text-align: left; text-indent: -14.2pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">f.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Mengkaji
adanya perubahan tingkat kesadaran(13.45).</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 219.65pt;" valign="top" width="293">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">S = Klien mengatakan badannya terasa lemas.</span></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">O =</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">TD </span><span style="mso-ansi-language: IN;">168</span><span lang="EN-US">/</span><span style="mso-ansi-language: IN;">88</span><span lang="EN-US"> mmHg dan MAP 1</span><span style="mso-ansi-language: IN;">13</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">HR </span><span style="mso-ansi-language: IN;">94</span><span lang="EN-US"> x/menit</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">RR 2</span><span style="mso-ansi-language: IN;">7</span><span lang="EN-US"> x/menit</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">SPO<sub>2 </sub>98%</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pupil isokor ukuran 2 : 2
reaksi +/+</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Kekuatan otot eks. Atas ki/
ka = </span><span style="mso-ansi-language: IN;">1</span><span lang="EN-US">/1</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Kekuatan otot eks. Bawah
ki/ka = </span><span style="mso-ansi-language: IN;">1</span><span lang="EN-US">/1</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Input IVFD </span><span style="mso-ansi-language: IN;">Futrolit</span> <span style="mso-ansi-language: IN;">45</span><span lang="EN-US">0 ml,</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">(13</span><span style="mso-ansi-language: IN;">.3</span><span lang="SV" style="mso-ansi-language: SV;">0)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Output Urine = </span><span style="mso-ansi-language: IN;">25</span><span lang="EN-US">0 ml</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">(13</span><span style="mso-ansi-language: IN;">.3</span><span lang="SV" style="mso-ansi-language: SV;">0)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Balance + </span><span style="mso-ansi-language: IN;">2</span><span lang="EN-US">00 ml</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">(13</span><span style="mso-ansi-language: IN;">.4</span><span lang="SV" style="mso-ansi-language: SV;">0)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">O<sub>2</sub> 3 liter/menit</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Kesadaran spoor <span style="mso-spacerun: yes;"> </span>GCS E3, V2, M2</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="SV" style="mso-ansi-language: SV;">(1</span><span style="mso-ansi-language: IN;">5.3</span><span lang="SV" style="mso-ansi-language: SV;">0)</span><span lang="EN-US"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">A =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Masalah teratasi sebagian</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">P =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Lanjutkan intervensi</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l114 level1 lfo94; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pantau vital sign</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l114 level1 lfo94; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Monitoring SPO<sub>2</sub> ,
ukuran pupil, kesimetrisan, dan reaksi.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l114 level1 lfo94; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Kaji kekuatan otot</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l114 level1 lfo94; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Monitor status cairan.</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l114 level1 lfo94; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pantau perubahan tingkat
kesadaran pasien.</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-right-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 164.7pt;" valign="top" width="220">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: center;">
<span lang="EN-US">Erfansyah S, Kep</span><span style="mso-ansi-language: IN;"></span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: center;">
<span style="mso-ansi-language: IN;">&</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: center;">
<span lang="EN-US">Prima Agustin W S,Kep</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 1;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.25pt;" valign="top" width="35">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 4; text-align: center;">
<span lang="EN-US" style="mso-bidi-font-weight: bold;">2</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 135.15pt;" valign="top" width="180">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Kelebihan volume cairan tubuh b.d gangguan mekanisme regulasi</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 163.0pt;" valign="top" width="217">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 17.65pt; mso-add-space: auto; text-align: justify;">
<span lang="FI" style="mso-ansi-language: FI;">Monitor balance cairan ( 13.00)</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 17.65pt; mso-add-space: auto; text-align: justify;">
<span lang="FI" style="mso-ansi-language: FI;">Monitor TTV (Perjam ( 07.00-14.00)</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 219.65pt;" valign="top" width="293">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">S=-</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">O= </span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 17.55pt; mso-add-space: auto; mso-list: l69 level2 lfo51; tab-stops: list 13.05pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Input futrolit</span><span style="mso-ansi-language: IN;"> + diit deabetasol </span><span style="mso-spacerun: yes;"> </span><span style="mso-ansi-language: IN;">45</span><span lang="EN-US">0</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="EN-US">ml</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 17.55pt; mso-add-space: auto; mso-list: l69 level2 lfo51; tab-stops: list 13.05pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Urin </span><span style="mso-ansi-language: IN;">250 </span><span lang="EN-US">ml</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 17.55pt; mso-add-space: auto; mso-list: l69 level2 lfo51; tab-stops: list 13.05pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">TTV terlampir</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 4.05pt; mso-add-space: auto; text-align: justify;">
<span lang="EN-US">A= Masalah
teratasi sebagian</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 4.05pt; mso-add-space: auto; text-align: justify;">
<span lang="EN-US">P= Lanjutkan
intervensi</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 164.7pt;" valign="top" width="220">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="EN-US">Erfansyah S, Kep</span><span style="mso-ansi-language: IN;"></span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">&</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="EN-US">Prima Agustin W S,Kep</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 2;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-left-themecolor: text1; mso-border-right-alt: solid windowtext .5pt; mso-border-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.25pt;" valign="top" width="35">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 68; text-align: justify;">
<b><span lang="EN-US">3</span></b></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 135.15pt;" valign="top" width="180">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Defisit perawatn diri total berhubungan dengan
intoleransi aktivitas</span><span style="mso-ansi-language: IN;"></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 163.0pt;" valign="top" width="217">
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l74 level1 lfo64; mso-yfti-cnfc: 64; text-align: justify; text-indent: -14.2pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Melakukan
oral hygiene</span><span lang="EN-US"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 219.65pt;" valign="top" width="293">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">S = -</span></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">O =</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l21 level1 lfo55; mso-yfti-cnfc: 64; text-align: justify; text-indent: -14.2pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pasien tampak bersih pada
baian mulut setelah dilakukan oral hygiene</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span style="mso-ansi-language: IN;">(</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">8</span><span lang="FI" style="mso-ansi-language: FI;">.00</span><span style="mso-ansi-language: IN;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l21 level1 lfo55; mso-yfti-cnfc: 64; text-align: justify; text-indent: -14.2pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pasien belum bisa melakukan
self care secara mandiri.</span><span style="mso-ansi-language: IN;"> (</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">8</span><span lang="FI" style="mso-ansi-language: FI;">.00</span><span style="mso-ansi-language: IN;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">A =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Masalah teratasi sebagian</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">P =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Lanjutkan Intervensi</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l40 level1 lfo95; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Bantu Pasien dalam ADL dan self
care.</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-right-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 164.7pt;" valign="top" width="220">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: center;">
<span lang="EN-US">Erfansyah S, Kep</span><span style="mso-ansi-language: IN;"></span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: center;">
<span style="mso-ansi-language: IN;">&</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: center;">
<span lang="EN-US">Prima Agustin W S,Kep</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 3;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.25pt;" valign="top" width="35">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 4; text-align: justify;">
<b><span lang="EN-US">4.</span></b></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 135.15pt;" valign="top" width="180">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Hambatan Mobilitas fisik berhubungan dengan kaku sendi atau kontraktur.</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 163.0pt;" valign="top" width="217">
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l113 level1 lfo66; text-align: justify; text-indent: -18.0pt;">
<span lang="NL" style="mso-ansi-language: NL;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="mso-ansi-language: NL;">Memonitor nutrisi<span style="mso-spacerun: yes;"> </span>dan sumber energi yang adekuat</span><span style="mso-ansi-language: IN;"> (07</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">0</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="NL" style="mso-ansi-language: NL;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l113 level1 lfo66; text-align: justify; text-indent: -18.0pt;">
<span lang="NL" style="mso-ansi-language: NL;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="mso-ansi-language: NL;">Melatih mobilisasi di tempat tidur.</span><span style="mso-ansi-language: IN;"> (07</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">0</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="NL" style="mso-ansi-language: NL;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l113 level1 lfo66; text-align: justify; text-indent: -18.0pt;">
<span lang="NL" style="mso-ansi-language: NL;"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="mso-ansi-language: NL;">Memonitor respon kardiovaskuler<span style="mso-spacerun: yes;"> </span>terhadap aktivitas (takikardi, disritmia,
sesak nafas, diaporesis, pucat, perubahan hemodinamik)</span></div>
<div class="MsoBodyTextIndent2" style="margin-left: 15.9pt; mso-list: l113 level1 lfo66; text-indent: -18.0pt;">
<span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Memantau respon oksigen pasien terhadap
aktivitas keperawatan</span><span style="mso-ansi-language: IN;"> (07</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">0</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="FI" style="mso-ansi-language: FI;"></span></div>
<div class="MsoBodyTextIndent2" style="margin-left: 15.9pt; mso-list: l113 level1 lfo66; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">e.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI;">Mempertahankan
pemberian oksigen</span><span style="mso-ansi-language: IN;"> (07</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">0</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="EN-US"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 219.65pt;" valign="top" width="293">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">S= </span><span style="mso-ansi-language: IN;">-</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">O =</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Vital sign perjam terlampir.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Pasien tampak lemas.</span><span style="mso-ansi-language: IN;"> (</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">9</span><span lang="FI" style="mso-ansi-language: FI;">.00</span><span style="mso-ansi-language: IN;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Latihan miring kanan miring kiri/ 2jam.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Kekuatan otot eks. Atas ki/ ka = </span><span style="mso-ansi-language: IN;">1</span><span lang="EN-US">/1</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Kekuatan otot eks. Bawah ki/ka = </span><span style="mso-ansi-language: IN;">1</span><span lang="EN-US">/1</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">O<sub>2</sub> nassa kanul 3 liter/menit.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; text-align: justify;">
<span lang="EN-US">A =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; text-align: justify;">
<span lang="EN-US">Masalah teratasi sebagian</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; text-align: justify;">
<span lang="EN-US">P =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; text-align: justify;">
<span lang="EN-US">Lanjutkan Intervensi</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l59 level1 lfo96; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pantau respon kardiovaskuler.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l59 level1 lfo96; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pantau respon oksigen tehadap
aktifitas keperawatan.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l59 level1 lfo96; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pantau kemampuan mobilisasi
pasien.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l59 level1 lfo96; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Ajarkan latihan ROM pasif.</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l59 level1 lfo96; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Mobilisasi tempat tidur mika/miki
per 2 jam</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 164.7pt;" valign="top" width="220">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="EN-US">Erfansyah S, Kep</span><span style="mso-ansi-language: IN;"></span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="mso-ansi-language: IN;">&</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="EN-US">Prima Agustin W S,Kep</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 4;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-left-themecolor: text1; mso-border-right-alt: solid windowtext .5pt; mso-border-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.25pt;" valign="top" width="35">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 68; text-align: justify;">
<b><span lang="EN-US">5.</span></b></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 135.15pt;" valign="top" width="180">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span style="mso-ansi-language: IN;">Ketidakefektifan </span><span lang="EN-US">perfusi jaringan cerebral berhubungan dengan gangguan aliran
arteri atau vena</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 163.0pt;" valign="top" width="217">
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l0 level1 lfo65; mso-yfti-cnfc: 64; text-align: left; text-indent: -14.2pt;">
<span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI;">Memonitor
TTV</span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l0 level1 lfo65; mso-yfti-cnfc: 64; text-align: left; text-indent: -14.2pt;">
<span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI;">Memonitor
SPO<sub>2</sub>, ukuran pupil, , kesimetrisan dan reaksi</span><span style="mso-ansi-language: IN;"> (13</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">0</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="FI" style="mso-ansi-language: FI;"></span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l0 level1 lfo65; mso-yfti-cnfc: 64; text-align: left; text-indent: -14.2pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Memonitor
tonus otot pergerakan </span><span style="mso-ansi-language: IN;">(13</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">0</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="SV" style="mso-ansi-language: SV;"></span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l0 level1 lfo65; mso-yfti-cnfc: 64; text-align: left; text-indent: -14.2pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Catat
perubahan pasien dalam merespon stimulus.</span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l0 level1 lfo65; mso-yfti-cnfc: 64; text-align: left; text-indent: -14.2pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">e.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Monitor
status cairan</span><span style="mso-ansi-language: IN;"> (13</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">0</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="SV" style="mso-ansi-language: SV;"></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 219.65pt;" valign="top" width="293">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">S : -</span></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">O =</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Vital sign terlampir</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pupil isokor ukuran 2 : 2
reaksi +/+</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Kekuatan otot eks. Atas ki/
ka = </span><span style="mso-ansi-language: IN;">1</span><span lang="EN-US">/1</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Kekuatan otot eks. Bawah ki/ka
= </span><span style="mso-ansi-language: IN;">1</span><span lang="EN-US">/1</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Input IVFD </span><span style="mso-ansi-language: IN;">Futrolit</span> <span style="mso-ansi-language: IN;">450</span><span lang="EN-US"> ml</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Output Urine = </span><span style="mso-ansi-language: IN;">25</span><span lang="EN-US">0 ml</span><span style="mso-ansi-language: IN;"> (14</span><span lang="FI" style="mso-ansi-language: FI;">.00</span><span style="mso-ansi-language: IN;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Balance </span><span style="mso-ansi-language: IN;">+</span><span lang="EN-US"> 200 ml</span><span style="mso-ansi-language: IN;"> (14</span><span lang="FI" style="mso-ansi-language: FI;">.00</span><span style="mso-ansi-language: IN;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">O<sub>2</sub> 3 liter/menit</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">A =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Masalah teratasi sebagian</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">P =</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Lanjutkan
intervensi</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l4 level1 lfo97; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pantau vital sign</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l4 level1 lfo97; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Monitoring SPO<sub>2</sub> ,
ukuran pupil, kesimetrisan, dan reaksi.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l4 level1 lfo97; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Kaji kekuatan otot</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l4 level1 lfo97; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Monitor status cairan.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l4 level1 lfo97; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pantau perubahan tingkat
kesadaran pasien.</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-right-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 164.7pt;" valign="top" width="220">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Nurul Hidayah S,kep</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 5;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.25pt;" valign="top" width="35">
<div align="center" class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 4; text-align: center;">
<span lang="EN-US" style="mso-bidi-font-weight: bold;">6</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 135.15pt;" valign="top" width="180">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Kelebihan volume cairan tubuh b.d gangguan mekanisme regulasi</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 163.0pt;" valign="top" width="217">
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 17.65pt; mso-add-space: auto; text-align: justify;">
<span lang="FI" style="mso-ansi-language: FI;">Monitor balance cairan ( 20.00)</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 17.65pt; mso-add-space: auto; text-align: justify;">
<span lang="FI" style="mso-ansi-language: FI;">Monitor TTV (Perjam (14.00-21.00)</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 219.65pt;" valign="top" width="293">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">S=-</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">O= </span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 17.55pt; mso-add-space: auto; mso-list: l69 level2 lfo51; tab-stops: list 13.05pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Input futrolit </span><span style="mso-ansi-language: IN;">70</span><span lang="EN-US">0 ml</span><span style="mso-ansi-language: IN;"> (20</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">3</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 17.55pt; mso-add-space: auto; mso-list: l69 level2 lfo51; tab-stops: list 13.05pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Urin </span><span style="mso-ansi-language: IN;">20</span><span lang="EN-US">0 ml</span><span style="mso-ansi-language: IN;"> (20</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">3</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 17.55pt; mso-add-space: auto; mso-list: l69 level2 lfo51; tab-stops: list 13.05pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Balance cairan </span><span style="mso-ansi-language: IN;">+5</span><span lang="EN-US">00</span><span style="mso-ansi-language: IN;"> (20</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">3</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 17.55pt; mso-add-space: auto; mso-list: l69 level2 lfo51; tab-stops: list 13.05pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">TTV terlampir</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 4.05pt; mso-add-space: auto; text-align: justify;">
<span lang="EN-US">A= Masalah
teratasi sebagian</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 4.05pt; mso-add-space: auto; text-align: justify;">
<span lang="EN-US">P= Lanjutkan
intervensi</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 164.7pt;" valign="top" width="220">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="EN-US">Nurul<span style="mso-spacerun: yes;"> </span>Hidayah S,Kep</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 6;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-left-themecolor: text1; mso-border-right-alt: solid windowtext .5pt; mso-border-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.25pt;" valign="top" width="35">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 68; text-align: justify;">
<b><span lang="EN-US">7</span></b></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 135.15pt;" valign="top" width="180">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Hambatan mobilitas fisik berhubungan dengan kaku sendi
atau kontraktur.</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 163.0pt;" valign="top" width="217">
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l37 level1 lfo67; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="NL" style="mso-ansi-language: NL;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="mso-ansi-language: NL;">Melatih mobilisasi ditempat tidur dan
ROM pasif.</span><span style="mso-ansi-language: IN;"> (16</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">0</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="NL" style="mso-ansi-language: NL;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l37 level1 lfo67; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="NL" style="mso-ansi-language: NL;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="mso-ansi-language: NL;">Memonitor respon kardiovaskuler<span style="mso-spacerun: yes;"> </span>terhadap aktivitas (takikardi, disritmia,
sesak nafas, diaporesis, pucat, perubahan hemodinamik)</span><span style="mso-ansi-language: IN;"> (16</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">0</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="NL" style="mso-ansi-language: NL;"></span></div>
<div class="MsoBodyTextIndent2" style="margin-left: 15.9pt; mso-list: l37 level1 lfo67; mso-yfti-cnfc: 64; text-indent: -18.0pt;">
<span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Memantau respon oksigen pasien terhadap
aktivitas keperawatan</span><span style="mso-ansi-language: IN;"> (15</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">0</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="FI" style="mso-ansi-language: FI;"></span></div>
<div class="MsoBodyTextIndent2" style="margin-left: 15.9pt; mso-list: l37 level1 lfo67; mso-yfti-cnfc: 64; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI;">Mempertahankan
pemberian oksigen</span><span style="mso-ansi-language: IN;"> (15</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">3</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="EN-US"></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 219.65pt;" valign="top" width="293">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">S= -</span></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">O =</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Vital sign terlampir</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Latihan ROM Pasif</span><span style="mso-ansi-language: IN;"> (16</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">3</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Tidak ada Tachikardia dan
sesak nafas,</span><span style="mso-ansi-language: IN;"> (16</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">3</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">O<sub>2</sub> nassa kanul 3
liter/menit.</span></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">A =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Masalah teratasi sebagian</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">P =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Lanjutkan Intervensi</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 24.6pt; mso-add-space: auto; mso-list: l48 level1 lfo98; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Latihan ROM Pasif</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 24.6pt; mso-add-space: auto; mso-list: l48 level1 lfo98; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Mobilisasi/ 4 jam</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 24.6pt; mso-add-space: auto; mso-list: l48 level1 lfo98; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pertahankan pemberian Oksigen</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-right-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 164.7pt;" valign="top" width="220">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Nurul Hidayah S,kep</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 7;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.25pt;" valign="top" width="35">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 4; text-align: justify;">
<b><span lang="EN-US">8.</span></b></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 135.15pt;" valign="top" width="180">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Defisit perawatan diri total berhubungan dengan intoleransi
aktivitas</span><span style="mso-ansi-language: IN;"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 163.0pt;" valign="top" width="217">
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l101 level1 lfo68; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Memonitor kemampuan klien untuk
perawatan diri yang mandiri.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l101 level1 lfo68; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Memonitor dan membantu
kebutuhan klien untuk alat-alat bantu untuk kebersihan diri, berpakaian,
berhias, toileting dan makan.</span><span style="mso-ansi-language: IN;"> (15</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">3</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="EN-US"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l101 level1 lfo68; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Membantu sampai klien mampu
secara utuh untuk melakukan self-care.</span><span style="mso-ansi-language: IN;"> (15</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">3</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="EN-US"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 219.65pt;" valign="top" width="293">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">S = -</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">O =</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l21 level1 lfo55; text-align: justify; text-indent: -14.2pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Pasien tampak bersih dan wangi setelah dilakukan personal hygiene.</span><span style="mso-ansi-language: IN;"> (16</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">3</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l21 level1 lfo55; text-align: justify; text-indent: -14.2pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Pasien belum bisa melakukan self care secara mandiri.</span><span style="mso-ansi-language: IN;"> (16</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">3</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; text-align: justify;">
<span lang="EN-US">A =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; text-align: justify;">
<span lang="EN-US">Masalah teratasi sebagian</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; text-align: justify;">
<span lang="EN-US">P =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; text-align: justify;">
<span lang="EN-US">Lanjutkan Intervensi</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-left: 20.1pt; mso-add-space: auto; mso-list: l55 level1 lfo99; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Bantu pasien dalam pemenuhan ADL
dan Self Care</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 164.7pt;" valign="top" width="220">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Nurul Hidayah S,kep</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 8;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-left-themecolor: text1; mso-border-right-alt: solid windowtext .5pt; mso-border-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.25pt;" valign="top" width="35">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 68; text-align: justify;">
<b><span lang="EN-US">9.</span></b></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 135.15pt;" valign="top" width="180">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span style="mso-ansi-language: IN;">Ketidakefektifan </span><span lang="EN-US">perfusi jaringan cerebral berhubungan dengan gangguan aliran
arteri atau vena</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 163.0pt;" valign="top" width="217">
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l91 level1 lfo69; mso-yfti-cnfc: 64; text-align: left; text-indent: -18.0pt;">
<span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI;">Memonitor
TTV</span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l91 level1 lfo69; mso-yfti-cnfc: 64; text-align: left; text-indent: -18.0pt;">
<span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI;">Memonitor
SPO<sub>2</sub>, ukuran pupil, , kesimetrisan dan reaksi</span><span style="mso-ansi-language: IN;"> (05</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">3</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="FI" style="mso-ansi-language: FI;"></span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l91 level1 lfo69; mso-yfti-cnfc: 64; text-align: left; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Memonitor
tonus otot pergerakan </span><span style="mso-ansi-language: IN;">(05</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">3</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="SV" style="mso-ansi-language: SV;"></span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l91 level1 lfo69; mso-yfti-cnfc: 64; text-align: left; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Catat
perubahan pasien dalam merespon stimulus.</span></div>
<div align="left" class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l91 level1 lfo69; mso-yfti-cnfc: 64; text-align: left; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">e.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="mso-ansi-language: SV;">Monitor
status cairan</span><span style="mso-ansi-language: IN;">(05</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">3</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="SV" style="mso-ansi-language: SV;"></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 219.65pt;" valign="top" width="293">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">S = -</span></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">O =</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Vital Sign terlampir.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pupil isokor ukuran 2 : 2
reaksi +/+</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Kekuatan otot eks. Atas ki/
ka = </span><span style="mso-ansi-language: IN;">1</span><span lang="EN-US">/1</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Kekuatan otot eks. Bawah
ki/ka = </span><span style="mso-ansi-language: IN;">1</span><span lang="EN-US">/1</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Input INFD </span><span style="mso-ansi-language: IN;">Futrolit + diit deabetasol 2150 (06</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">3</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Output Urine = </span><span style="mso-ansi-language: IN;">1150</span><span lang="EN-US"> ml </span><span style="mso-ansi-language: IN;">(06</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">3</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Cairan Balance </span><span style="mso-ansi-language: IN;">+</span> <span style="mso-ansi-language: IN;">10</span><span lang="EN-US">00 ml.</span><span style="mso-ansi-language: IN;"> (06</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">3</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">O<sub>2</sub> 3 liter/menit</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Kesadaran Compos Mentis GCS E3,
V2, M2</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">A =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Masalah teratasi sebagian.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">P =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2.8pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Lanjutkan intervensi</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.6pt; mso-add-space: auto; mso-list: l6 level1 lfo100; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.5pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pantau vital sign</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.6pt; mso-add-space: auto; mso-list: l6 level1 lfo100; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.5pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Monitoring SPO<sub>2</sub> ,
ukuran pupil, kesimetrisan, dan reaksi.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.6pt; mso-add-space: auto; mso-list: l6 level1 lfo100; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.5pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Kaji kekuatan otot</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.6pt; mso-add-space: auto; mso-list: l6 level1 lfo100; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.5pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Monitor status cairan.</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 15.6pt; mso-add-space: auto; mso-list: l6 level1 lfo100; mso-yfti-cnfc: 64; text-align: justify; text-indent: -13.5pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Pantau perubahan tingkat
kesadaran pasien.</span><span lang="EN-US"></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-right-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 164.7pt;" valign="top" width="220">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Siti Suwarsih S,Kep</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 9;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.25pt;" valign="top" width="35">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 4; text-align: justify;">
<b><span lang="EN-US">10</span></b></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 135.15pt;" valign="top" width="180">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: IN;">Intoleransi aktifitas b</span><span lang="EN-US">erhubungan
dengan ketidakseimbangan antara suplay oksigen dengan kebutuhan</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 163.0pt;" valign="top" width="217">
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l86 level1 lfo70; text-align: justify; text-indent: -14.2pt;">
<span lang="NL" style="mso-ansi-language: NL;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="mso-ansi-language: NL;">Memonitor nutrisi<span style="mso-spacerun: yes;"> </span>dan sumber energi yang adekuat.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l86 level1 lfo70; text-align: justify; text-indent: -14.2pt;">
<span lang="NL" style="mso-ansi-language: NL;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="mso-ansi-language: NL;">Melatih mobilisasi ditempat tidur dan
ROM pasif.</span><span style="mso-ansi-language: IN;">(07.30)</span><span lang="NL" style="mso-ansi-language: NL;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l86 level1 lfo70; text-align: justify; text-indent: -14.2pt;">
<span lang="NL" style="mso-ansi-language: NL;"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="mso-ansi-language: NL;">Memonitor respon kardiovaskuler<span style="mso-spacerun: yes;"> </span>terhadap aktivitas (takikardi, disritmia,
sesak nafas, diaporesis, pucat, perubahan hemodinamik)</span><span style="mso-ansi-language: IN;"> (06</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">3</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="NL" style="mso-ansi-language: NL;"></span></div>
<div class="MsoBodyTextIndent2" style="margin-left: 15.9pt; mso-list: l86 level1 lfo70; text-indent: -14.2pt;">
<span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Memantau respon oksigen pasien terhadap
aktivitas keperawatan</span><span style="mso-ansi-language: IN;"> (06</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">4</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="FI" style="mso-ansi-language: FI;"></span></div>
<div class="MsoBodyTextIndent2" style="margin-left: 15.9pt; mso-list: l86 level1 lfo70; text-indent: -14.2pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">e.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="mso-ansi-language: FI;">Mempertahankan
pemberian oksigen</span><span style="mso-ansi-language: IN;"> (06</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">3</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="EN-US"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 219.65pt;" valign="top" width="293">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">S= -</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">O =</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Vital Sign Terlampir</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Latihan ROM Pasif</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Tidak ada Tachikardia dan sesak nafas,\</span><span style="mso-ansi-language: IN;"> (09</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">3</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l66 level1 lfo53; text-align: justify; text-indent: -13.05pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">O<sub>2</sub> nassa kanul 3 liter/menit.</span><span style="mso-ansi-language: IN;"> (08</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">3</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="EN-US"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; text-align: justify;">
<span lang="EN-US">A =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; text-align: justify;">
<span lang="EN-US">Masalah teratasi sebagian</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; text-align: justify;">
<span lang="EN-US">P =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 4.95pt; text-align: justify;">
<span lang="EN-US">Lanjutkan Intervensi</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 24.6pt; mso-add-space: auto; mso-list: l110 level1 lfo101; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Latihan ROM Pasif</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 24.6pt; mso-add-space: auto; mso-list: l110 level1 lfo101; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Mobilisasi ditempat tidur</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 24.6pt; mso-add-space: auto; mso-list: l110 level1 lfo101; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Kolaborasi dalam penurunan suplay
oksigen 2 liter/menit.</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 164.7pt;" valign="top" width="220">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Siti Suwarsih S,Kep</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 10; mso-yfti-lastrow: yes;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-left-themecolor: text1; mso-border-right-alt: solid windowtext .5pt; mso-border-themecolor: text1; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 26.25pt;" valign="top" width="35">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 68; text-align: justify;">
<b><span lang="EN-US">11.</span></b></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 135.15pt;" valign="top" width="180">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Defisit perawatn diri total berhubungan dengan
intoleransi aktivitas</span><span style="mso-ansi-language: IN;"></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 163.0pt;" valign="top" width="217">
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l122 level1 lfo71; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Memonitor kemampuan klien untuk
perawatan diri yang mandiri.</span><span style="mso-ansi-language: IN;">
(05.20)</span><span lang="SV" style="mso-ansi-language: SV;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l122 level1 lfo71; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Memonitor dan membantu
kebutuhan klien untuk alat-alat bantu untuk kebersihan diri, berpakaian,
berhias, toileting dan makan.</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span style="mso-ansi-language: IN;">(05.00)</span><span lang="EN-US"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 15.9pt; mso-list: l122 level1 lfo71; mso-yfti-cnfc: 64; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Membantu sampai klien mampu
secara utuh untuk melakukan self-care.</span><span style="mso-ansi-language: IN;"> (07.30)</span><span lang="EN-US"></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: black 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: windowtext .5pt; mso-border-right-alt: windowtext .5pt; mso-border-style-alt: solid; mso-border-top-alt: black 1.0pt; mso-border-top-alt: solid black 1.0pt; mso-border-top-themecolor: text1; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 219.65pt;" valign="top" width="293">
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">S = -</span></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">O =</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l21 level1 lfo55; mso-yfti-cnfc: 64; text-align: justify; text-indent: -14.2pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">pasien menunjukkan
peningkatan kesadaran penuh.Pasien tampak bersih dan wangi setelah dilakukan
personal hygiene.</span><span style="mso-ansi-language: IN;"> (08</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">3</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="EN-US"></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 15.85pt; mso-add-space: auto; mso-list: l21 level1 lfo55; mso-yfti-cnfc: 64; text-align: justify; text-indent: -14.2pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US">Pasien tampak belum bisa
melakukan self care secara mandiri.</span><span style="mso-ansi-language: IN;"> (08</span><span lang="FI" style="mso-ansi-language: FI;">.</span><span style="mso-ansi-language: IN;">3</span><span lang="FI" style="mso-ansi-language: FI;">0</span><span style="mso-ansi-language: IN;">)</span><span lang="EN-US"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">A =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Masalah teratasi sebagian</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; mso-yfti-cnfc: 64; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">P =</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1.65pt; mso-yfti-cnfc: 64; text-align: justify;">
<span lang="EN-US">Lanjutkan Intervensi</span></div>
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<span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;">Bantu pasien dalam ADL dan Self
care</span></div>
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<span lang="EN-US">Siti Suwarsih S,Kep</span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">BAB IV</span></b></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">PEMBAHASAN</span></b></div>
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<span lang="EN-US">Stroke adalah penyebab kematian yang
utama.Pola penyebab kematian di rumah sakit yang utama dari data Departemen
Kesehatan Republik Indonesia yang menyebutkan bahwa stroke menempati urutan
pertama sebagai penyebab kematian di RS.Stroke merupakan penyebab kematian
nomor tiga setelah penyakit jantung dan kanker secara global.</span><span style="mso-ansi-language: IN;"></span></div>
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<span style="color: black; mso-ansi-language: IN;">Penulis
melakukan tahap pengkajian antara lain : Identitas klien, riwayat keperawatan,
keluhan utama, pemeriksaan fisik serta pemeriksaan penunjang untuk menegakkan
suatu diagnosa.</span><span style="mso-ansi-language: IN;"></span></div>
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<span lang="EN-US" style="color: black;">Setelah
mendapatkan data dari pengkajian, selanjutnya data tersebut diinterpretasikan
dan dianalisa untuk mengetahui masalah keperawatan yang muncul. Kemudian
penulis menentukan dan menegakkan diagnosa keperawatan utama</span><span style="color: black; mso-ansi-language: IN;">yaitu :</span><span style="mso-ansi-language: IN;">Ketidakefektifan </span><span lang="EN-US">perfusi jaringan cerebral
berhubungan dengan gangguan aliran arteri atau vena</span><span style="mso-ansi-language: IN;">, </span><span lang="EN-US">Defisit perawatan diri
total berhubungan dengan kelemaha</span><span style="mso-ansi-language: IN;">n, </span><span lang="EN-US">Hambatan mobilitas fisik berhubungan dengan kaku sendi atau
kontraktur</span><span style="mso-ansi-language: IN;">, </span><span lang="EN-US">Ketidakseimbangan
nutrisi kurang dari kebutuhan tubuh berhubungan dengan penyakit kronis (Stroke)</span><span style="mso-ansi-language: IN;"></span></div>
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<span lang="EN-US" style="color: black;">Sedangkan pada
teoritis diagnosa keperawatan yang mungkin muncul </span><span lang="SV" style="mso-ansi-language: SV;">Ketidakefektifan pembersihan jalan napas berhubungan
dengan akumulasi skret sekunder adanya kelemahan neuromuskuler</span><span style="mso-ansi-language: IN;">, </span><span lang="SV" style="mso-ansi-language: SV;">Ketidakefektifan perfusi jaringan cerebral berhubungan dengangangguan
aliran arteri atau vena</span><span style="mso-ansi-language: IN;">, </span><span lang="SV" style="mso-ansi-language: SV;">Ketidakseimbangan cairan dan elektrolit:
kurang dari yang dibutuhkan berhubungan dengan intake yang tidak adequate</span><span lang="SV" style="font-family: TimesNewRomanPSMT; mso-ansi-language: SV; mso-bidi-font-family: TimesNewRomanPSMT; mso-fareast-font-family: "Times New Roman"; mso-hansi-font-family: TimesNewRomanPSMT;">, </span><span lang="EN-US">Ketidakseimbangan nutrisi
kurang dari kebutuhan tubuh berhubungan dengan kesulitan menelan dan mengunyah</span><span style="mso-ansi-language: IN;">, </span><span lang="SV" style="mso-ansi-language: SV;">Intoleransi aktifvitas berhubungan dengan </span><span lang="EN-US">ketidakseimbangan
antara suplay oksigen dengan kebutuhan</span><span style="mso-ansi-language: IN;">, </span><span lang="SV" style="mso-ansi-language: SV;">Gangguan komunikasi
verbal berhubungn dengan gangguan pada N. Fasialis</span><span style="mso-ansi-language: IN;">, </span><span lang="SV" style="mso-ansi-language: SV;">Defisit perawatan diri berhubungan dengan intoleransi aktivitas</span><span style="mso-ansi-language: IN;"></span></div>
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<span lang="FI" style="color: black; mso-ansi-language: FI;">Dalam tinjauan teoritis perencanaan keperawatan ditujukan pada setiap
masalah yang muncul, sedangkan pada kasus</span><span style="color: black; mso-ansi-language: IN;">, </span><span lang="FI" style="color: black; mso-ansi-language: FI;">penulis menambahkan jangka waktu pencapaian tujuan. Hal ini juga penting
untuk mengevaluasi tindakan yang diberikan pada klien untuk mengetahui perkembangan
status kesehatan klien</span><span style="color: black; mso-ansi-language: IN;">.</span></div>
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<span lang="EN-US" style="color: black;">Pada tahap
perencanaan didalam tindakan yang nyata yang diharapkan dari tindakan
keperawatan yang telah dilaksanakan dengan intervensi yang disusun, walaupun
ada sebagian yang tidak bisa dilaksanakan karena minimnya waktu yang diberikan
dan sarana yang kurang memadai.Walaupun demikian dalam melaksanakan asuhan
keperawatan penulis mendapat hambatan dan kesulitan yang berupa </span><span style="color: black; mso-ansi-language: IN;">intervensi yang diberikan hanya Tiga
hari saja</span><span lang="EN-US" style="color: black;">.</span><span style="color: black; mso-ansi-language: IN; mso-themecolor: text1;"></span></div>
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<span lang="EN-US" style="color: black;">Pada kasus Ny.</span><span style="color: black; mso-ansi-language: IN;">Hdilakukan </span><span lang="EN-US">Pelaksanaan
Pelaksanaan ROM dapat diaplikasikan minimal 2 kali sehari, hal ini sesuai
dengan jurnal <b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;">Sri Puguh Kristiyawati dan Febrina Sukmaningrum (2011) dengan judul
Efektivitas Range Of Motion (ROM) Aktif-Asistif<span style="mso-spacerun: yes;">
</span>: Spherical Grip Terhadap Peningkatan Kekuatan Otot Ekstrimitas Atas
pada Paien Stroke di RSUD Tugurejo Semarang</i></b>. Berdasarkan penelitian,
Latihan ROM dapat dilakukan karena sang</span><span style="mso-ansi-language: IN;">a</span><span lang="EN-US">t efektif bagi pemulihan pasien stroke yang
mengalami hemipharesis.</span><span lang="EN-US" style="mso-ansi-language: IN;"> </span><span lang="EN-US">Latihan gerak secara berulang membuat konsentrasi untuk melakukan
gerakan berulang dengan kualitas sebaik mungkin.</span><span style="mso-ansi-language: IN;"></span></div>
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<span lang="EN-US">Jurnal</span><span style="mso-ansi-language: IN;"> dari </span><b><i><span lang="EN-US">Dianna C. Haryono1, Andreanus A.
Soemardji1, Felesia Fanty</span></i><i style="mso-bidi-font-style: normal;"><span lang="EN-US"> Peranan Terapi Akupunktur “GI” pada Penderita <span style="mso-bidi-font-style: italic;">Stroke </span></span></i></b><b style="mso-bidi-font-weight: normal;"><i><span style="mso-ansi-language: IN;">di
Pel</span><span lang="EN-US">ayanan Akupunktur UPT Kesehatan Institut Teknologi
Bandung</span></i></b><b style="mso-bidi-font-weight: normal;"><i><span style="mso-ansi-language: IN;">. </span></i></b><span lang="EN-US">Akupunktur “GI”
merupakan teknik penusukan jarum yang menggabungkan ilmu pengobatan timur dan
ilmu kedokteran barat berdasarkan prinsip pemijatan dengan titik utama 2 di
leher, 3 di perut dan 2 di tungkai bawah. WHO (World Health Organization)
menyatakan akupunktur sebagai pengobatan efektif menangani kasus stroke.
Penelitian ini bertujuan untuk menguji peranan terapi Akupunktur “GI” secara
klinis pada penderita stroke. Kajian observasional dilakukan selama ± 3 bulan
(Februari – April 2011) kepada pasien stroke yang diterapi Akupunktur “GI” di
Klinik Akupunktur Sukamenak dan UPT Bumi Medika Ganesa ITB.</span><span style="mso-ansi-language: IN;"></span></div>
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<span style="mso-ansi-language: IN;">Akupunktur “GI”
berperan efektif dalam meningkatkan aktivitas motorik pasien stroke yang
ditunjukkan melalui peningkatan kemandirian dalam melakukan aktivitas
sehari-hari, peningkatan kemampuan dalam mengontrol tubuh dan melakukan
berbagai gerakan, serta peningkatan kekuatan fisik. Pada pasien NY. H tidak
dilakukannya terapi akupuntur GI.</span></div>
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<span lang="EN-US">Menurut Wahjoepramono (2005) obat
-obat ini berfungsi untuk menghambat pembentukan zat-zat toksin seperti nitrit
oksida, beberapa radikal bebas dan aktivasi phospolidase. Jika hal ini tidak
dihambat, maka dalam beberapa jam akan terjadi kerusakan yang <i style="mso-bidi-font-style: normal;">irreversible</i>. Obat yang memberikan efek
neuroprotektif adalah citicolin, piracetam, dan nimodipin.Hal ini sesuai dengan
terapi medis yang diperoleh pasien, yaitu citicolin injeksi intravena dengan
dosis 2 x 500 gram.Obat-obat tersebut memperbaiki cedera otak yang disebabkan
otak dengan mencegah otak mengalami iskemik, sehingga tidak menyebabkan infark
(Junaidi, 2011)</span><span style="mso-ansi-language: IN;">. Pada klien NY. H diberikan
terapi injeksi </span><span lang="EN-US">citicolin</span><span style="mso-ansi-language: IN;">.</span></div>
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<span lang="EN-US" style="color: black;">Evaluasi
merupakan tahap terakhir dari proses keperawatan. Kegiatan evaluasi ini adalah
membandingkan hasil yang telah dicapai setelah implementasi keperawatan dengan
tujuan yang diharapkan dalam perencanaan.</span><span style="mso-ansi-language: IN;"></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">BAB V</span></b></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">PENUTUP</span></b></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">A.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Kesimpulan</span></b></div>
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<span lang="EN-US">Penelitian
berskala cukup besar dilakukan oleh ASNA (AseanNeurologic Association) di 28
Rumah Sakit di seluruh Indonesia. Penelitian inidilakukan pada penderita stroke
akut yang dirawat di Rumah Sakit (hospitalbased study) dan dilakukan survey
mengenai faktor-faktor risiko, lamaperawatan dan mortalitas serta
morbiditasnya. Hasilnya menunjukkan bahwapenderita laki-laki lebih banyak dari
perempuan dengan profil usia di bawah45 tahun cukup banyak yaitu 11,8%, usia
45-64 tahun berjumlah 54,7% dandi atas usia 65 tahun 33,5%.
(Misbach,2007).Penilaian yang akurat dan tepat dari Activities of Daily Living
(ADL)pada pasien pasca stroke sangat penting untuk menilai outcome
dariperawatan stroke. Kwon dkk melakukan penilaian disabilitas pada pasienpasca
stroke dengan menilai Barthel Index (BI), motor component ofFunctional
Independence Measure (M-FIM) dan modified Rankin Scale(mRS). Mereka mendapatkan
hubungan erat antara BI, M-FIM dan mRS</span><span style="mso-ansi-language: IN;"></span></div>
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<span lang="EN-US">dalam
menilai disabilitas pasien stroke secara umum (Kwon dkk,2004).Pada klien dengan
stroke, terdapat beberapa masalah keperawatan yang muncul diantaranya adalah
ketidakefektifan perfusi jaringan serebral, ketidakseimbangan nutrisi kurang
dari kebutuhan tubuh, hambatan mobilitas fisik, dan defisit perawatan
diri.Untuk diagnosa hambatan mobilitas fisik, salah satu implementasi yang
dapat dilakukan adalah dengan latihan rentang gerak atau <i style="mso-bidi-font-style: normal;">Range of Motion</i> (ROM).Untuk pasien dengan penurunan kesadaran dapat
dilakukan ROM pasif, dan untuk pasien yang tidak mengalami penurunan kesadaran,
dapat dilakukan ROM aktif.</span><span style="mso-ansi-language: IN;"></span></div>
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<span lang="EN-US">Berdasarkan
tujuan keperawatan yang telah ditetapkan, masalah keperawatan yang teratasi
adalah ketidakseimbangan nutrisi kurang dari kebutuhan tubuh.Untuk </span><span style="mso-ansi-language: IN;">3</span><span lang="EN-US"> diagnosa keperawatan
lainnya, belum dapat teratasi sepenuhnya.Dikarenakan keterbatasan waktu
sehingga mahasiswa hanya mengobservasi klien selama 3 hari, dari tanggal</span><span style="mso-ansi-language: IN;"> 30 Mei</span><span lang="EN-US">–1 </span><span style="mso-ansi-language: IN;">Juni</span><span lang="EN-US"> 2013.</span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">B.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US">Saran</span></b></div>
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<span lang="EN-US">Dalam
kesimpulan diatas maka penulis dapat mengemukakan saran – saran sebagai berikut
:</span><span style="mso-ansi-language: IN;"></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="color: black; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></b><b><span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Bagi Mahasiswa</span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="color: black;"></span></b></div>
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<span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Hendaknya lebih
proaktif, cepat dan tanggap dalam menghadapi segala situasi dan kondisi yang
dihadapi baik dalam teori atau kasus lapangan, khususnya pada proses kegawat
daruratan.</span></div>
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<b><span style="mso-ansi-language: IN; mso-fareast-language: IN;">2.</span></b><b><span style="font-size: 7.0pt; line-height: 150%; mso-ansi-language: IN; mso-fareast-language: IN;">
</span></b><b><span style="mso-ansi-language: IN; mso-fareast-language: IN;">Lahan
Praktek</span></b><span style="mso-ansi-language: IN; mso-fareast-language: IN;"></span></div>
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<span style="mso-ansi-language: IN; mso-fareast-language: IN;">Diharapkan
pada lahan lebih meningkat pelayanan.</span></div>
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<span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Dalam melakukan asuhan keperawatan klien dengan stroke, perawat
dapat mengimplementasikan ROM, minimal 2 kali dalam sehari.</span><span style="mso-ansi-language: IN; mso-fareast-language: IN;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 72.0pt; mso-add-space: auto; mso-list: l28 level1 lfo104; text-align: justify; text-indent: -18.0pt;">
<span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US">Dalam melakukan asuhan keperawatan pada klien dengan stroke, perawat
dapat mengimplementasikan merubah posisi pasien secara berkala, dengan minimal
2 jam sekali.</span><span style="mso-ansi-language: IN; mso-fareast-language: IN;"></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 72.0pt; mso-add-space: auto; mso-list: l28 level1 lfo104; text-align: justify; text-indent: -18.0pt;">
<span style="mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="mso-ansi-language: IN;">Dan melakukan terapi akupuntur GI pada pasien
stroke jika perlu.</span><span style="mso-ansi-language: IN; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 49.65pt; text-align: justify;">
<br /></div>
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<b><span style="mso-ansi-language: IN; mso-fareast-language: IN;">3.</span></b><b><span style="font-size: 7.0pt; line-height: 150%; mso-ansi-language: IN; mso-fareast-language: IN;">
</span></b><b><span style="mso-ansi-language: IN; mso-fareast-language: IN;">Institusi
Pendidikan</span></b><span style="mso-ansi-language: IN; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 49.65pt; text-align: justify;">
<span style="mso-ansi-language: IN; mso-fareast-language: IN;">Dapat
membimbing dalam proses pembuatan asuhan keperawatan khususnya pada kegawat
daruratan dengan sabar dan teliti serta memotivasi para mahasiswa dalam segi
mental dan spiritual.</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; text-align: justify; text-indent: 42.5pt;">
<br /></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US">DAFTAR PUSTAKA</span></b></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
<div class="MsoNormal" style="margin-left: 1.0cm; text-indent: -1.0cm;">
<span lang="EN-US">Arief Mansjoer, dkk. 2007. Kapita Selekta Kedokteran. Jilid 1, Edisi
3. Jakarta : Media Aesculapius FKUI</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US" style="font-size: 11.0pt; mso-bidi-font-size: 12.0pt;">Potter dan Perry. 2006. <i>Buku Ajar Fundamental Keperawatan</i>.
Jakarta : EGC.</span></div>
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<br /></div>
<div class="MsoNormal" style="margin-left: 1.0cm; text-indent: -1.0cm;">
<span lang="EN-US">Smeltzer,S.C& Bare,B.G.<span style="mso-spacerun: yes;">
</span>2006.<i style="mso-bidi-font-style: normal;"> Buku Ajar Keperawatan
Medikal Bedah.</i>Edisi 8.Jakarta : EGC</span></div>
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<br /></div>
<div class="MsoNormal">
<span lang="EN-US">Sudoyo,W.et al. 2006.<span style="mso-spacerun: yes;"> </span><i style="mso-bidi-font-style: normal;">Buku
Ajar Ilmu Penyakit Dalam Jilid III.</i>Edisi 4.Jakarta : Pusat </span></div>
<div class="MsoNormal" style="text-indent: 36.0pt;">
<span lang="EN-US">Penerbitan
Departemen Ilmu Penyakit Dalam.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: 1.0cm; text-indent: -1.0cm;">
<span lang="EN-US">Wilkinson, JM & Ahern,N. 2011. Buku <i style="mso-bidi-font-style: normal;">Saku Diagnosis Keperawatan, Intervensi NIC, kriteria hasil NOC</i>.Edisi
9.Jakarta : EGC</span></div>
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<br /></div>
<div class="MsoNormal" style="margin-left: 1.0cm; text-indent: -1.0cm;">
<span lang="EN-US" style="font-size: 11.5pt; mso-bidi-font-weight: bold;">Kristyawati, et
al. 2011.<i style="mso-bidi-font-style: normal;">Efektivitas Range of Motion
(ROM) : Aktif – Asistif : Spherical Grip Terhadap Peningkatan Kekuatan Otot
Ekstrimitas Atas pada Pasien Stroke di RSUD Tugurejo Semarang.</i></span></div>
<div class="MsoNormal" style="margin-left: 1.0cm; text-indent: -1.0cm;">
<br /></div>
<div class="MsoNormal" style="margin-left: 1.0cm; text-indent: -1.0cm;">
<span lang="EN-US" style="font-size: 11.5pt; mso-bidi-font-weight: bold;">Santana,A&Fathi,
A 2005. <i style="mso-bidi-font-style: normal;">Pemenuhan Mobilisasi Pada Pasien
Post Stroke Di Ruang Unit Stroke Rumah Sakit UmumDr. Pirngadi Medan. </i></span></div>
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<br /></div>
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ERFANSYAH. HRhttp://www.blogger.com/profile/07497970584312798191noreply@blogger.com21tag:blogger.com,1999:blog-2228299828902052163.post-63021982381369012972013-03-13T01:19:00.000-07:002022-07-13T22:48:39.920-07:00ASUHAN KEPERAWATAN KLIEN DENGAN CIDERA KEPALA (NANDA,, NOC, NIC) <!--[if gte mso 9]><xml>
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<b><span style="font-family: "Times New Roman","serif"; font-size: 13.5pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">ASUHAN KEPERAWATAN KLIEN DENGAN CIDERA KEPALA (NANDA,,
NOC, NIC) </span></b></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm;">
<b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">A.</span></b><b><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span></b><b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pengertian</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Cidera
kepala adalah pukulan atau benturan mendadak pada kepala dengan atau tanpa
kehilangan kesadaran (Tucker, 1998).</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Cidera
kepala (terbuka dan tertutup) terdiri dari fraktur tengkorak, commusio (gegar)
serebri, contusio (memar) serebri, laserasi dan perdarahan serebral yaitu
diantaranya subdural, epidural, intraserebral, dan batang otak (Doenges,
2000:270).</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Cidera
kepala diklasifikasikan berdasarkan:</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">1.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Keadaan
kulit kepala dan tulang tengkorak</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">a.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Cidera
kepala terbuka</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">b.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Cidera
kepala tertutup</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">2.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Cidera pada
jaringan otak (secara anatomis)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">a.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Commusio
serebri (gegar otak)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">b.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Edema
serebri</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">c.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Contusio
serebri (memar otak)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">d.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Laserasi</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 2.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">1).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Hematoma epidural</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 2.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">2).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Hematoma subdural</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 2.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">3).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Perdarahan sub arakhnoid</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 14.15pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">(Ergan,
1998:642)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">3.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Adanya
penetrasi durameter (secara mekanisme)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">a.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Cidera
tumpul</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 2.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">1).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kecepatan tinggi (tabrakan otomobil)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 2.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">2).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kecepatan rendah (terjatuh, dipukul)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">b.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Cidera
tembus</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">c.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Luka tembus
peluru dan cidera tembus lainnya</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">4.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Tingkat
keparahan cidera (berdasarkan GCS)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">a.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Cidera Kepala
Ringan (CKR) GCS 13-15</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">b.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Cidera
Kepala Sedang (CKS) GCS 9-12</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">c.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Cidera
Kepala Berat (CKB) GCS 3-8</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">GCS (Glasgow
Coma Scale)</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; margin-left: 35.4pt; mso-padding-alt: 0cm 0cm 0cm 0cm; mso-yfti-tbllook: 1184; width: 593px;">
<tbody>
<tr style="height: 384.95pt; mso-yfti-firstrow: yes; mso-yfti-irow: 0; mso-yfti-lastrow: yes;">
<td style="height: 384.95pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 284.6pt;" valign="top" width="379">
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-indent: -.6pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Membuka
mata (E)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.75pt; text-indent: -14.15pt;">
<span style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;">§</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Spontan<span style="mso-tab-count: 4;"> </span> </span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.75pt; text-indent: -14.15pt;">
<span style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;">§</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Dipanggil/diperintah<span style="mso-tab-count: 3;"> </span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.75pt; text-indent: -14.15pt;">
<span style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;">§</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Tekanan
pada jari/rangsang nyeri<span style="mso-tab-count: 1;"> </span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.75pt; text-indent: -14.15pt;">
<span style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;">§</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Tidak berespon
<span style="mso-tab-count: 1;"> </span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-indent: -27.75pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Respon
Verbal (V)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.75pt; text-indent: -14.15pt;">
<span style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;">§</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Orientasi
baik: dapat bercakap-cakap<span style="mso-tab-count: 1;"> </span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.75pt; text-indent: -14.15pt;">
<span style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;">§</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Bingung,
dapat bercakap tapi disorientasi</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.75pt; text-indent: -14.15pt;">
<span style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;">§</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kata yang
diucapkan tidak tepat, kacau</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.75pt; text-indent: -14.15pt;">
<span style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;">§</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Tidak
dapat dimengerti, mengerang<span style="mso-tab-count: 1;"> </span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.75pt; text-indent: -14.15pt;">
<span style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;">§</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Tidak
bersuara dengan rangsang nyeri</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-indent: -1.0cm;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Respon
Motorik</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.15pt; text-indent: -14.15pt;">
<span style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;">§</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Mematuhi
perintah<span style="mso-tab-count: 2;"> </span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.15pt; text-indent: -14.15pt;">
<span style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;">§</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Menunjuk
lokasi nyeri<span style="mso-tab-count: 2;"> </span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.15pt; text-indent: -14.15pt;">
<span style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;">§</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Reaksi
fleksi<span style="mso-tab-count: 4;"> </span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.15pt; text-indent: -14.15pt;">
<span style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;">§</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Fleksi
abnormal thdp nyeri (postur dekortikasi)<span style="mso-tab-count: 1;"> </span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.15pt; text-indent: -14.15pt;">
<span style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;">§</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Ekstensi
abnormal<span style="mso-tab-count: 5;"> </span><span style="mso-spacerun: yes;"> </span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.15pt; text-indent: -14.15pt;">
<span style="font-family: Wingdings; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;">§</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Tidak ada
respon, flacid<span style="mso-tab-count: 4;"> </span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
</td>
<td style="height: 384.95pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 160.25pt;" valign="top" width="214">
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">4</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">3</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">2</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">2</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">5</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">4</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">3</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">2</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">1</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">6</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">5</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">4</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">3</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">2</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">1</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">5.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Berdasarkan morfologi</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">a.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Fraktur
tengkorak</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 2.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">1).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kranium: linear/ stelatum, depresi/ non depresi,
terbuka/ tertutup.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 2.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">2).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Basis: dengan/ tanpa kebocoran cairan cerebrospinal,
dengan/ tanpa kelumpuhan nervus VIII</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">b.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Lesi intra
cranial</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 2.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">1).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Foxal: epidural, subdural, intraserebral</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 2.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">2).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Difus: konkusi ringan/ klasik, cidera aksonal difus.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">B.</span></b><b><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span></b><b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Etiologi</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Cidera
kepala merupakan salah satu penyebab kematian dan kecacatan utama pada kelompok
usia produktif dan sebagian besar terjadi akibat kecelakaan lalu lintas (
Mansjoer, 2000:3).</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Penyebab
cidera kepala antara lain: kecelakaan lalu lintas, perkelahian, terjatuh, dan
cidera olah raga. Cidera kepala terbuka sering disebabkan oleh peluru atau
pisau (Corkrin, 2001:175).</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">C.</span></b><b><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span></b><b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Patofisiologi</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Cidera
kepala dapat terjadi karena benturan benda keras, cidera kulit kepala, tulang
kepala, jaringan otak, baik terpisah maupun seluruhnya.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Cidera
bervariasi dari luka kulit yang sederhana sampai gegar otak, luka terbuka dari
tengkotak, disertai kerusakan otak, cidera pada otak, bisa berasal dari trauma
langsung maupun tidak langsung pada kepala.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Trauma tak
langsung disebabkan karena tingginya tahanan atau kekuatan yang merobek terkena
pada kepala akibat menarik leher.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Trauma
langsung bila kepala langsung terbuka, semua itu akibat terjadinya akselerasi,
deselerasi, dan pembentukan rongga, dilepaskannya gas merusak jaringan syaraf.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Trauma
langsung juga menyebabkan rotasi tengkorak dan isinya. Kerusakan itu bisa
terjadi seketika atau menyusul rusaknya otak oleh kompresi, goresan, atau
tekanan.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Cidera yang
terjadi waktu benturan mungkin karena memar pada permukaan otak, laserasi
substansia alba, cidera robekan, atau hemmorarghi.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Sebagai
akibat, cidera skunder dapat terjadi sebagai kemampuan auto regulasi serebral
dikurangi atau tidak ada pada area cidera, konsekuensinya meliputi hiperemia
(peningkatan volume darah, peningkatan permeabilitas kapiler, serta
vasodilatasi arterial, tekanan intra cranial) (Huddak & Gallo, 1990:226).</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pengaruh
umum cidera kepala juga bisa menyebabkan kram, adanya penumpukan cairan yang
berlebihan pada jaringan otak, edema otak akan menyebabkan peningkatan tekanan
intra cranial yang dapat menyebabkan herniasi dan penekanan pada batang otak
(Price and Wilson, 1995:1010).</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">D.</span></b><b><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span></b><b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Manifestasi Klinik</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Berdasarkan
anatomis</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">1.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Gegar otak
(comutio selebri)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">a.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Disfungsi
neurologis sementara dapat pulih dengan atau tanpa kehilangan kesadaran</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">b.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pingsan
kurang dari 10 menit atau mungkin hanya beberapa detik/menit</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">c.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Sakit kepala,
tidak mampu konsentrasi, vertigo, mungkin muntah</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">d.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kadang
amnesia retrogard</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">2.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Edema
serebri</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">a.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pingsan
lebih dari 10 menit</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">b.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Tidak ada
kerusakan jaringan otak</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">c.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Nyeri
kepala, vertigo, muntah</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">3.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Memar otak
(kontusio selebri)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">a.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pecahnya
pembuluh darah kapiler, tanda dan gejalanya bervariasi tergantung lokasi dan
derajad</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">b.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Ptechie dan
rusaknya jaringan saraf disertai perdarahan</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">c.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Peningkatan
tekanan intracranial (PTIK)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">d.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Penekanan
batang otak</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">e.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Penurunan
kesadaran</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">f.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Edema jaringan otak</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">g.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Defisit
neurologis</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">h.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Herniasi</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">4.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Laserasi</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">a.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Hematoma
Epidural</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">“talk dan
die” tanda klasik: penurunan kesadaran ringan saat benturan, merupakan periode
lucid (pikiran jernih), beberapa menit s.d beberapa jam, menyebabkan penurunan
kesadaran dan defisit neurologis (tanda hernia):</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 56.15pt; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">1).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">kacau mental → koma</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 56.15pt; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">2).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">gerakan bertujuan → tubuh dekortikasi atau
deseverbrasi</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 56.15pt; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">3).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">pupil isokhor → anisokhor</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt 72.0pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">b.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Hematoma
subdural</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 56.15pt; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">1).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Akumulasi darah di bawah lapisan duramater diatas
arachnoid, biasanya karena aselerasi, deselerasi, pada lansia, alkoholik.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 56.15pt; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">2).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Perdarahan besar menimbulkan gejala-gejala seperti
perdarahan epidura</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 56.15pt; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">3).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Defisit neurologis dapat timbul berminggu-minggu
sampai dengan berbulan-bulan</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 56.15pt; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">4).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Gejala biasanya 24-48 jam post trauma (akut)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 56.15pt; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">5).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">perluasan massa lesi</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 56.15pt; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">6).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">peningkatan TIK</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 56.15pt; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">7).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">sakit kepala, lethargi, kacau mental, kejang</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 56.15pt; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">8).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">disfasia</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">c.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Perdarahan
sub arachnoid</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 56.15pt; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">1).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Nyeri kepala hebat</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 56.15pt; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">2).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kaku kuduk</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Berdasarkan nilai
GCS (Glasgow Coma Scale)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">1.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Cidera
kepala Ringan (CKR)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">a.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">GCS 13-15</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">b.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kehilangan
kesadaran/amnesia <30 menit="" span=""><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></30></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">c.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Tidak ada
fraktur tengkorak</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">d.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Tidak ada
kontusio celebral, hematoma</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">2.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Cidera
Kepala Sedang (CKS)<span style="mso-tab-count: 1;"> </span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">a.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">GCS 9-12</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">b.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kehilangan
kesadaran dan atau amnesia >30 menit tetapi kurang dari 24 jam</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">c.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Dapat
mengalami fraktur tengkorak</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">3.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Cidera
Kepala Berat (CKB)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">a.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">GCS 3-8</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">b.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kehilangan
kesadaran dan atau terjadi amnesia > 24 jam </span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">c.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Juga meliputi
kontusio celebral, laserasi, atau hematoma intracranial (Hudak dan Gallo,
1996:226)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">E.</span></b><b><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span></b><b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Komplikasi</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 18.0pt; text-align: justify; text-indent: 17.85pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kemunduran pada kondisi pasien mungkin karena
perluasan hematoma intrakranial, edema serebral progresif, dan herniasi otak</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 18.0pt; text-align: justify;">
<i><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Edema
serebral dan herniasi</span></i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 18.0pt; text-align: justify; text-indent: 17.85pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Edema serebral adalah penyebab paling umum peningkatan
TIK pada pasien yang mendapat cedera kepala, puncak pembengkakan yang terjadi
kira kira 72 jam setelah cedera. TIK meningkat karena ketidakmampuan tengkorak
untuk membesar meskipun peningkatan volume oleh pembengkakan otak diakibatkan
trauma.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 18.0pt; text-align: justify; text-indent: 17.85pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Sebagai akibat dari edema dan peningkatan TIK, tekanan
disebarkan pada jaringan otak dan struktur internal otak yang kaku. Bergantung
pada tempat pembengkakan, perubahan posisi kebawah atau lateral otak (herniasi)
melalui atau terhadap struktur kaku yang terjadi menimbulkan iskemia, infark,
dan kerusakan otak irreversible, kematian.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 18.0pt; text-align: justify; text-indent: .15pt;">
<i><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Defisit neurologik dan psikologik</span></i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 18.0pt; text-align: justify; text-indent: 17.85pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pasien cedera kepala dapat mengalami paralysis saraf
fokal seperti anosmia (tidak dapat mencium bau bauan) atau abnormalitas gerakan
mata, dan defisit neurologik seperti afasia, defek memori, dan kejang post
traumatic atau epilepsy. Pasien mengalami sisa penurunan psikologis organic
(melawan, emosi labil) tidak punya malu, emosi agresif dan konsekuensi
gangguan.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 18.0pt; text-align: justify; text-indent: .15pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Komplikasi lain secara traumatik:</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 18.0pt list 1.0cm 63.0pt; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">1.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Infeksi
sitemik (pneumonia, ISK, sepsis)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 18.0pt list 1.0cm 63.0pt; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">2.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Infeksi
bedah neurologi (infeksi luka, osteomielitis, meningitis, ventikulitis, abses
otak)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 18.0pt list 1.0cm 63.0pt; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">3.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Osifikasi
heterotropik (nyeri tulang pada sendi sendi)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 18.0pt; text-align: justify; text-indent: .3pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Komplikasi lain:</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 18.0pt list 1.0cm 63.0pt; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">1.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Peningkatan
TIK</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 18.0pt list 1.0cm 63.0pt; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">2.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Hemorarghi</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 18.0pt list 1.0cm 63.0pt; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">3.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kegagalan
nafas</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 18.0pt list 1.0cm 63.0pt; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">4.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Diseksi
ekstrakranial</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 18.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">F.</span></b><b><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span></b><b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Penatalaksanaan</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">1.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Penatalaksanaan
Keperawatan</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">a.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Menjamin
kelancaran jalan nafas dan control vertebra cervicalis</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">b.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Menjaga
saluran nafas tetap bersih, bebas dari secret</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">c.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Mempertahankan
sirkulasi stabil</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">d.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Melakukan
observasi tingkat kesadaran dan tanda tanda vital</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">e.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Menjaga
intake cairan elektrolit dan nutrisi jangan sampai terjadi hiperhidrasi</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">f.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Menjaga kebersihan kulit untuk mencegah terjadinya decubitus</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">g.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Mengelola
pemberian obat sesuai program</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">2.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Penatalaksanaan
Medis</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">a.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Oksigenasi
dan IVFD</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">b.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Terapi untuk
mengurangi edema serebri (anti edema)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Dexamethasone
10 mg untuk dosis awal, selanjutnya:</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 2.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">1).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">5 mg/6 jam untuk hari I dan II</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 2.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">2).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">5 mg/8 jam untuk hari III</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 2.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">3).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">5 mg/12 jam untuk hari IV</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 2.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">4).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">5 mg/24 jam untuk hari V</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">c.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Terapi
neurotropik: citicoline, piroxicam</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">d.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Terapi anti
perdarahan bila perlu</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">e.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Terapi
antibiotik untuk profilaksis</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">f.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Terapi antipeuretik bila demam</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">g.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Terapi anti
konvulsi bila klien kejang</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">h.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Terapi
diazepam 5-10 mg atau CPZ bila klien gelisah</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">i.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Intake cairan tidak boleh > 800 cc/24 jam selama 3-4 hari</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">G.</span></b><b><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span></b><b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pemeriksaan
Diagnostik</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">1.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">X Ray
tengkorak</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">2.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">CT Scan</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">3.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Angiografi</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">4.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pemeriksaan
neurologist</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">H.</span></b><b><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span></b><b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Asuhan Keperawatan CKS</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">1.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pengkajian</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Data fokus
yang perlu dikaji:</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">a.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Riwayat
kesehatan meliputi: keluhan utama, kapan cidera terjadi, penyebab cidera,
riwayat tak sadar, amnesia, riwayat kesehatan yang lalu, dan riwayat kesehatan
keluarga.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">b.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pemeriksaan
fisik</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 2.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">1).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Keadaan umum</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 2.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">2).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pemeriksaan persistem</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 70.9pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">a).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Sistem persepsi dan sensori (pemeriksaan panca indera:
penglihatan, pendengaran, penciuman, pengecap, dan perasa)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 70.9pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">b).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Sistem persarafan (tingkat kesadaran/ nilai GCS,
reflek bicara, pupil, orientasi waktu dan tempat)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 70.9pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">c).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Sistem pernafasan (nilai frekuensi nafas, kualitas,
suara, dan kepatenan jalan nafas)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 70.9pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">d).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Sistem kardiovaskuler (nilai TD, nadi dan irama,
kualitas, dan frekuensi)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 70.9pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">e).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Sistem gastrointestinal (nilai kemampuan menelan,
nafsu makan/ minum, peristaltik, eliminasi)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 70.9pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">f).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Sistem integumen ( nilai warna, turgor, tekstur dari
kulit, luka/ lesi)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 70.9pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">g).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Sistem reproduksi</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 70.9pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">h).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Sistem perkemihan (nilai frekuensi b.a.k, volume
b.a.k)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">c.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pola fungsi
kesehatan</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 2.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">1).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pola persepsi dan pemeliharaan kesehatan (termasuk
adakah kebiasaan merokok, minum alcohol, dan penggunaan obat obatan)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 2.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">2).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pola aktivitas dan latihan (adakah keluhan lemas,
pusing, kelelahan, dan kelemahan otot)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 2.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">3).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pola nutrisi dan metabolisme (adakah keluhan mual,
muntah)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 2.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">4).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pola eliminasi</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 2.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">5).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pola tidur dan istirahat</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 2.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">6).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pola kognitif dan perceptual</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 2.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">7).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Persepsi diri dan konsep diri</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 2.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">8).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pola toleransi dan koping stress</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 2.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">9).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pola seksual dan reproduktif</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 2.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">10).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
</span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pola hubungan dan peran</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 2.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">11).</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
</span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pola nilai dan keyakinan</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">2.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Diagnosa
Keperawatan</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Diagnosa
keperawatan yang mungkin muncul pada klien dengan cidera kepala adalah sebagai
berikut:</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 46.35pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">1)</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Perfusi jaringan tidak efektif (spesifik serebral) berhubungan dengan
aliran arteri dan atau vena terputus.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 46.35pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">2)</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Nyeri akut berhubungan dengan agen injury fisik.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 46.35pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">3)</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Hipertermi berhubungan dengan trauma (cidera jaringan otak, kerusakan
batang otak)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 46.35pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">4)</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pola nafas tak efektif berhubungan dengan hipoventilasi</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 46.35pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">5)</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kerusakan persepsi sensori berhubungan dengan penurunan kemampuan kognitif,
afektif, dan motorik)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 46.35pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">6)</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kerusakan mobilitas fisik berhubungan dengan penurunan kemampuan kognitif,
motorik, dan afektif.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 46.35pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">7)</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Defisit perawatan diri: makan/ mandi, toileting berhubungan dengan
kelemahan fisik dan nyeri.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 46.35pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">8)</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kurang pengetahuan berhubungan dengan penurunan kemampuan kognitif,
motorik, dan afektif.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 46.35pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">9)</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Resiko aspirasi berhubungan dengan penurunan tingkat kesadaran.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 46.35pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">10)</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Resiko kekurangan
volume cairan berhubungan dengan status hipermetabolik.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 46.35pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">11)</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Resiko
tinggi infeksi berhubungan dengan trauma/ laserasi kulit kepala</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 46.35pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">12)</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Resiko
tinggi terhadap perubahan nutrisi: kurang dari kebutuhan tubuh berhubungan
dengan mual, muntah.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 46.35pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial; mso-fareast-language: IN;">13)</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; line-height: 150%; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">PK: peningkatan
TIK dengan proses desak ruang akibat penumpukan cairan/ darah di dalam otak.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm;">
<b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">3. Rencana Perawatan </span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div align="center">
<table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; mso-padding-alt: 0cm 0cm 0cm 0cm; mso-yfti-tbllook: 1184; width: 624px;">
<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td style="border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt;">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: center;">
<b><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">No</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 109.9pt;" width="147">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: center;">
<b><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Diagnosa</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: center;">
<b><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Keperawatan<span style="mso-spacerun: yes;"> </span></span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 125.6pt;" width="167">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: center;">
<b><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Tujuan dan kriteria hasil</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 209.65pt;" width="280">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: center;">
<b><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Intervensi</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 1;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt;" valign="top">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: center;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">1</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 109.9pt;" valign="top" width="147">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Perfusi
jaringan tak efektif (spesifik sere-bral) b.d aliran arteri dan atau vena
terputus, dengan batasan karak-teristik:</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 18.0pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
</span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Perubahan
respon motorik</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 18.0pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
</span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Perubahan
status mental</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 18.0pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
</span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Perubahan
respon pupil</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 18.0pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
</span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Amnesia
retrograde (gang-guan memori)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 125.6pt;" valign="top" width="167">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm;">
<b><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">NOC:</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">1.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Status sirkulasi</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">2.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Perfusi jaringan serebral</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Setelah
dilakukan tindakan keperawatan selama ….x 24 jam, klien mampu men-capai :</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">1.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Status sirkulasi dengan indikator:</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol; mso-fareast-language: IN;">·</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Symbol; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Tekanan darah sis-tolik dan
diastolik dalam rentang yang diharapkan</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol; mso-fareast-language: IN;">·</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Symbol; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Tidak ada ortostatik hipotensi</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol; mso-fareast-language: IN;">·</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Symbol; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Tidak ada tanda tan-da PTIK</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">2.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Perfusi jaringan serebral, dengan indicator :</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol; mso-fareast-language: IN;">·</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Symbol; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Klien mampu berko-munikasi dengan
je-las dan sesuai ke-mampuan</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol; mso-fareast-language: IN;">·</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Symbol; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Klien menunjukkan perhatian,
konsen-trasi, dan orientasi</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol; mso-fareast-language: IN;">·</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Symbol; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Klien mampu mem-proses informasi</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol; mso-fareast-language: IN;">·</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Symbol; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Klien mampu mem-buat keputusan
de-ngan benar</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol; mso-fareast-language: IN;">·</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Symbol; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Tingkat kesadaran klien membaik</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 209.65pt;" valign="top" width="280">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm;">
<b><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Monitor
Tekanan Intra Kranial</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">1.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Catat perubahan respon klien terhadap stimu-lus /
rangsangan</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">2.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Monitor TIK klien dan respon neurologis terhadap
aktivitas</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">3.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Monitor intake dan output</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">4.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pasang restrain, jika perlu</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">5.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Monitor suhu dan angka leukosit</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">6.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kaji adanya kaku kuduk</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">7.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kelola pemberian antibiotik</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">8.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Berikan posisi dengan kepala elevasi 30-40<sup>O</sup>
dengan leher dalam posisi netral</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">9.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Minimalkan stimulus dari lingkungan</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">10.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Beri jarak antar tindakan keperawatan untuk meminimalkan peningkatan TIK</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">11.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kelola obat obat untuk mempertahankan TIK dalam batas spesifik</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm;">
<b><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Monitoring
Neurologis (2620)</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">1.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Monitor ukuran, kesimetrisan, reaksi dan bentuk
pupil</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">2.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Monitor tingkat kesadaran klien</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">3.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Monitor tanda-tanda vital</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">4.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Monitor keluhan nyeri kepala, mual, dan muntah</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">5.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Monitor respon klien terhadap pengobatan</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">6.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Hindari aktivitas jika TIK meningkat</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">7.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Observasi kondisi fisik klien</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm;">
<b><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Terapi
Oksigen (3320)</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">1.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Bersihkan jalan nafas dari secret</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">2.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pertahankan jalan nafas tetap efektif</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">3.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Berikan oksigen sesuai instruksi</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">4.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Monitor aliran oksigen, kanul oksigen, dan
humidifier</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">5.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Beri penjelasan kepada klien tentang pentingnya
pemberian oksigen</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">6.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Observasi tanda-tanda hipoventilasi</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">7.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Monitor respon klien terhadap pemberian oksigen</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">8.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Anjurkan klien untuk tetap memakai oksigen selama
aktivitas dan tidur</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 2;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt;" valign="top">
<div align="center" class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: center;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">2</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 109.9pt;" valign="top" width="147">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Nyeri akut
b.d dengan agen injuri fisik, dengan batasan karakteristik:</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 18.0pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
</span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Laporan
nyeri ke-pala secara verbal atau non verbal</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 18.0pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
</span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Respon
autonom (perubahan vital sign, dilatasi pupil)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 18.0pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
</span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Tingkah
laku eks-presif (gelisah, me-nangis, merintih)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 18.0pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
</span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Fakta dari
observasi</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 18.0pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
</span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Gangguan
tidur (mata sayu, menye-ringai, dll)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 125.6pt;" valign="top" width="167">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm;">
<b><span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">NOC:</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 12.6pt list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">1.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Nyeri terkontrol</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 12.6pt list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">2.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Tingkat Nyeri</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 12.6pt list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">3.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Tingkat kenyamanan</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 12.6pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Setelah
dilakukan asuhan keperawatan selama …. x 24 jam, klien dapat :</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 12.6pt; text-align: justify; text-indent: -12.6pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">1.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Mengontrol nyeri, de-ngan indikator:</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 32.2pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
</span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Mengenal
faktor-faktor penyebab</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 32.2pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
</span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Mengenal
onset nyeri</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 32.2pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
</span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Tindakan
pertolong-an non farmakologi</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 32.2pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
</span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Menggunakan
anal-getik</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 32.2pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
</span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Melaporkan
gejala-gejala nyeri kepada tim kesehatan.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 32.2pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
</span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Nyeri terkontrol</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 12.6pt; text-align: justify; text-indent: -12.6pt;">
<span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL; mso-fareast-font-family: Arial; mso-fareast-language: IN;">2.</span><span lang="NL" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: NL; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Menunjukkan
tingkat nyeri, dengan indikator:</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 32.2pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
</span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Melaporkan
nyeri</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 32.2pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
</span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Frekuensi
nyeri</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 32.2pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
</span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Lamanya
episode nyeri</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 32.2pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
</span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Ekspresi
nyeri; wa-jah</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 32.2pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
</span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Perubahan
respirasi rate</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 32.2pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
</span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Perubahan
tekanan darah</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 32.2pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
</span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kehilangan
nafsu makan</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">3.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Tingkat kenyamanan, dengan indicator :</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 29.85pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
</span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Klien
melaporkan kebutuhan tidur dan istirahat tercukupi</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 209.65pt;" valign="top" width="280">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Manajemen nyeri (1400) </span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">1.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kaji keluhan
nyeri, lokasi, karakteristik, onset/durasi, frekuensi, kualitas, dan beratnya
nyeri.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">2.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Observasi
respon ketidaknyamanan secara verbal dan non verbal.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">3.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pastikan
klien menerima perawatan analgetik dg tepat.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">4.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Gunakan
strategi komunikasi yang efektif untuk mengetahui respon penerimaan klien
terhadap nyeri.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">5.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Evaluasi
keefektifan penggunaan kontrol nyeri </span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">6.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Monitoring
perubahan nyeri baik aktual maupun potensial.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">7.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Sediakan
lingkungan yang nyaman.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">8.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kurangi
faktor-faktor yang dapat menambah ungkapan nyeri.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">9.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Ajarkan
penggunaan tehnik relaksasi sebelum atau sesudah nyeri berlangsung.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">10.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kolaborasi
dengan tim kesehatan lain untuk memilih tindakan selain obat untuk
meringankan nyeri.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">11.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Tingkatkan
istirahat yang adekuat untuk meringankan nyeri.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><span style="mso-spacerun: yes;"> </span><b><span lang="SV">Manajemen
pengobatan (2380)</span></b></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">1.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Tentukan obat
yang dibutuhkan klien dan cara mengelola sesuai dengan anjuran/ dosis.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">2.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Monitor efek
teraupetik dari pengobatan.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">3.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Monitor
tanda, gejala dan efek samping obat.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">4.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Monitor
interaksi obat.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">5.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Ajarkan pada
klien / keluarga cara mengatasi efek samping pengobatan.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">6.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Jelaskan
manfaat pengobatan yg dapat mempengaruhi gaya hidup klien.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><span style="mso-spacerun: yes;"> </span>Pengelolaan analgetik</span></b><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> <b>(2210)</b></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">1.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Periksa
perintah medis tentang obat, dosis & frekuensi obat analgetik.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">2.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Periksa
riwayat alergi klien.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">3.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pilih obat
berdasarkan tipe dan beratnya nyeri.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">4.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pilih cara
pemberian IV atau IM untuk pengobatan, jika mungkin.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">5.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Monitor vital
sign sebelum dan sesudah pemberian analgetik. </span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">6.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kelola jadwal
pemberian analgetik yang sesuai. </span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">7.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Evaluasi
efektifitas dosis analgetik, observasi tanda dan gejala efek samping, misal
depresi pernafasan, mual dan muntah, mulut kering, & konstipasi.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">8.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kolaborasi
dgn dokter untuk obat, dosis & cara pemberian yg diindikasikan.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">9.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Tentukan
lokasi nyeri, karakteristik, kualitas, dan keparahan sebelum pengobatan.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">10.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Berikan obat
dengan prinsip 5 benar</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">11.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Dokumentasikan
respon dari analgetik dan efek yang tidak diinginkan</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 3;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt;" valign="top">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: center;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">3</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 109.9pt;" valign="top" width="147">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Defisit
self care b.d de-ngan kelelahan,<span style="mso-spacerun: yes;"> </span>nyeri</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 125.6pt;" valign="top" width="167">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-indent: -32.0pt;">
<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">NOC:</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-indent: -32.0pt;">
<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Perawatan diri : </span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">(mandi, Makan Toiletting, berpakaian)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Setelah diberi motivasi perawatan selama ….x24<span style="mso-spacerun: yes;"> </span>jam, ps mengerti cara memenuhi ADL secara
bertahap sesuai kemam-puan, dengan kriteria :</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 11.35pt; text-align: justify; text-indent: -11.35pt;">
<span lang="NL" style="color: #333333; font-family: Symbol; font-size: 10.0pt; mso-ansi-language: NL; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol; mso-fareast-language: IN;">·</span><span lang="NL" style="color: #333333; font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: NL; mso-fareast-font-family: Symbol; mso-fareast-language: IN;">
</span><span lang="NL" style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Mengerti secara seder-hana cara<span style="mso-spacerun: yes;"> </span>mandi, makan, toileting, dan berpakaian
serta mau mencoba se-cara aman tanpa cemas</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 11.35pt; text-align: justify; text-indent: -11.35pt;">
<span lang="NL" style="color: #333333; font-family: Symbol; font-size: 10.0pt; mso-ansi-language: NL; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol; mso-fareast-language: IN;">·</span><span lang="NL" style="color: #333333; font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: NL; mso-fareast-font-family: Symbol; mso-fareast-language: IN;">
</span><span lang="NL" style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Klien mau berpartisipasi dengan senang hati tanpa
keluhan dalam memenuhi ADL</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 209.65pt;" valign="top" width="280">
<div class="MsoNormal" style="line-height: normal; margin-left: 24.25pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; mso-outline-level: 5; text-align: justify; text-indent: -24.25pt;">
<b><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">NIC:
Membantu perawatan diri klien Mandi<span style="mso-spacerun: yes;">
</span>dan toiletting</span></b><b><span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></b></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Aktifitas:</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: -13.3pt;">
<span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL; mso-fareast-font-family: Arial; mso-fareast-language: IN;">1.</span><span lang="NL" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: NL; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Tempatkan
alat-alat mandi di tempat yang mudah dikenali dan mudah dijangkau klien</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: -13.3pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">2.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Libatkan klien dan dampingi</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: -13.3pt;">
<span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL; mso-fareast-font-family: Arial; mso-fareast-language: IN;">3.</span><span lang="NL" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: NL; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Berikan
bantuan selama klien masih mampu mengerjakan sendiri</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; mso-outline-level: 6; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">NIC: ADL Berpakaian</span></b><b><span style="font-family: "Times New Roman","serif"; font-size: 7.5pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></b></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Aktifitas:</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: -13.3pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">1.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Informasikan pada klien dalam
memilih pakaian selama perawatan</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: -13.3pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">2.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Sediakan pakaian di tempat yang
mudah dijangkau</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: -13.3pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">3.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Bantu berpakaian yang sesuai</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: -13.3pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">4.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Jaga privcy klien</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: -13.3pt;">
<span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL; mso-fareast-font-family: Arial; mso-fareast-language: IN;">5.</span><span lang="NL" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: NL; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Berikan
pakaian pribadi yg digemari dan sesuai</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">NIC: ADL Makan</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: -13.3pt;">
<span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL; mso-fareast-font-family: Arial; mso-fareast-language: IN;">1.</span><span lang="NL" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: NL; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Anjurkan
duduk dan berdo’a bersama teman</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: -13.3pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;">2.</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Dampingi saat makan</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: -13.3pt;">
<span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL; mso-fareast-font-family: Arial; mso-fareast-language: IN;">3.</span><span lang="NL" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: NL; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Bantu jika
klien belum mampu dan beri contoh</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: -13.3pt;">
<span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL; mso-fareast-font-family: Arial; mso-fareast-language: IN;">4.</span><span lang="NL" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: NL; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Beri rasa
nyaman saat makan</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 4; mso-yfti-lastrow: yes;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt;" valign="top">
<div align="center" class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: center;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">4</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 109.9pt;" valign="top" width="147">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">PK:
peningkatan tekan-an intrakranial b.d pro-ses desak ruang akibat penumpukan
cairan / darah di dalam otak (Carpenito, 1999)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Batasan karakteristik :</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 18.0pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
</span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Penurunan
kesadar-an (gelisah, disori-entasi)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 18.0pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
</span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Perubahan
motorik dan persepsi sensasi</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 18.0pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
</span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Perubahan
tanda vi-tal (TD meningkat, nadi kuat dan lambat)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 18.0pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
</span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pupil
melebar, re-flek pupil menurun</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 18.0pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
</span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Muntah</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 18.0pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
</span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Klien
mengeluh mual</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 18.0pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-</span><span style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
</span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Klien
mengeluh pandangan kabur dan diplopia</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 125.6pt;" valign="top" width="167">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Setelah dilakukan tindakan keperawatan selama
....x 24 jam dapat mencegah atau meminimalkan komplikasi dari peningkatan
TIK, dengan kriteria :</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 11.35pt; text-align: justify; text-indent: -11.35pt;">
<span lang="NL" style="font-family: Symbol; font-size: 10.0pt; mso-ansi-language: NL; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol; mso-fareast-language: IN;">·</span><span lang="NL" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: NL; mso-fareast-font-family: Symbol; mso-fareast-language: IN;"> </span><span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kesadaran stabil (orien-asi
baik)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 11.35pt; text-align: justify; text-indent: -11.35pt;">
<span lang="NL" style="font-family: Symbol; font-size: 10.0pt; mso-ansi-language: NL; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol; mso-fareast-language: IN;">·</span><span lang="NL" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: NL; mso-fareast-font-family: Symbol; mso-fareast-language: IN;"> </span><span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pupil isokor, diameter 1mm</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 11.35pt; text-align: justify; text-indent: -11.35pt;">
<span lang="NL" style="font-family: Symbol; font-size: 10.0pt; mso-ansi-language: NL; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol; mso-fareast-language: IN;">·</span><span lang="NL" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: NL; mso-fareast-font-family: Symbol; mso-fareast-language: IN;"> </span><span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Reflek baik</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 11.35pt; text-align: justify; text-indent: -11.35pt;">
<span lang="NL" style="font-family: Symbol; font-size: 10.0pt; mso-ansi-language: NL; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol; mso-fareast-language: IN;">·</span><span lang="NL" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: NL; mso-fareast-font-family: Symbol; mso-fareast-language: IN;"> </span><span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Tidak mual</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 11.35pt; text-align: justify; text-indent: -11.35pt;">
<span lang="NL" style="font-family: Symbol; font-size: 10.0pt; mso-ansi-language: NL; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol; mso-fareast-language: IN;">·</span><span lang="NL" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: NL; mso-fareast-font-family: Symbol; mso-fareast-language: IN;"> </span><span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Tidak muntah</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 209.65pt;" valign="top" width="280">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">1.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pantau tanda
dan gejala peningkatan TIK</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span lang="SV" style="font-family: Wingdings; font-size: 10.0pt; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;">§</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kaji respon membuka mata, respon motorik, dan verbal, (GCS)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span lang="SV" style="font-family: Wingdings; font-size: 10.0pt; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;">§</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kaji perubahan tanda-tanda vital</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span lang="SV" style="font-family: Wingdings; font-size: 10.0pt; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;">§</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kaji respon pupil</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span lang="SV" style="font-family: Wingdings; font-size: 10.0pt; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;">§</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Catat gejala dan tanda-tanda: muntah, sakit kepala, lethargi, gelisah,
nafas keras, gerakan tak bertujuan, perubahan mental</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">2.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Tinggikan
kepala 30-40<sup>O </sup>jika tidak ada kontra indikasi</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">3.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Hindarkan situasi
atau manuver sebagai berikut:</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span lang="SV" style="font-family: Wingdings; font-size: 10.0pt; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;">§</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Masase karotis</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span lang="SV" style="font-family: Wingdings; font-size: 10.0pt; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;">§</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Fleksi dan rotasi leher berlebihan</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span lang="SV" style="font-family: Wingdings; font-size: 10.0pt; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;">§</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Stimulasi anal dengan jari, menahan nafas, dan mengejan</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 1.0cm; text-align: justify; text-indent: -14.15pt;">
<span lang="SV" style="font-family: Wingdings; font-size: 10.0pt; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;">§</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Wingdings; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Perubahan posisi yang cepat</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">4.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Ajarkan klien
untuk ekspirasi selama perubahan posisi</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">5.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Konsul dengan
dokter untuk pemberian pe-lunak faeces, jika perlu</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">6.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pertahankan
lingkungan yang tenang</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">7.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Hindarkan
pelaksanaan urutan aktivitas yang dapat meningkatkan TIK (misal: batuk,
penghisapan, pengubahan posisi, meman-dikan)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">8.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Batasi waktu
penghisapan pada tiap waktu hingga 10 detik</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">9.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Hiperoksigenasi
dan hiperventilasi klien se-belum dan sesudah penghisapan</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">10.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Konsultasi
dengan dokter tentang pemberian lidokain profilaktik sebelum penghisapan</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">11.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pertahankan
ventilasi optimal melalui posisi yang sesuai dan penghisapan yang teratur</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">12.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Jika
diindikasikan, lakukan protokol atau kolaborasi dengan dokter untuk terapi
obat yang mungkin termasuk sebagai berikut:</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">13.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Sedasi,
barbiturat (menurunkan laju meta-bolisme serebral)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">14.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Antikonvulsan
(mencegah kejang)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">15.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Diuretik
osmotik (menurunkan edema serebral)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">16.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Diuretik non
osmotik (mengurangi edema serebral)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">17.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Steroid
(menurunkan permeabilitas kapiler, membatasi edema serebral)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;">18.</span><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 7.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial; mso-fareast-language: IN;"> </span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pantau status
hidrasi, evaluasi cairan masuk dan keluar)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
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<b><span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">DAFTAR
PUSTAKA</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: center;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: -36.0pt;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: -36.0pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Brunner dan
Suddarth. 2001. <i>Buku Ajar Keperawatan Medikal Bedah. </i>Volume II. Edisi 8.
Jakarta: Penerbit Buku Kedokteran EGC.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: -36.0pt;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: -36.0pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Carpenito,
L.J. 1999. <i>Rencana Asuhan dan Dokumentasi Keperawatan dan Masalah Kolaborasi</i>.
Edisi 8. Jakarta: Penerbit Buku Kedokteran EGC.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: -36.0pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Doenges,
M.E. 1999. <i>Rencana Asuhan Keperawatan</i>. Edisi 3. Jakarta: Penerbit Buku
Kedokteran EGC.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: -36.0pt;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: -36.0pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Hudak dan
Gallo. 1996. <i>Keperawatan Kritis Pendekatan Holistik</i>. Volume II. Edisi 6.
Jakarta: Penerbit Buku Kedokteran EGC.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: -36.0pt;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: -36.0pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Marion
Johnson, dkk. 2000. <i>Nursing Outcomes Classification (NOC) Second</i> <i>Edition</i>.
Mosby.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: -36.0pt;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: -36.0pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Mc. Closkey
dan Buleccheck. 2000. <i>Nursing Interventions Classification (NIC) Second
Edition</i>. Mosby.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: -36.0pt;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: -36.0pt;">
<span style="font-family: "Arial","sans-serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">NANDA. 2005.
<i>Nursing Diagnosis: Definition and Classification</i>. Philadelphia: North
American Nursing Diagnosis Association.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
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<![endif]-->ERFANSYAH. HRhttp://www.blogger.com/profile/07497970584312798191noreply@blogger.com0tag:blogger.com,1999:blog-2228299828902052163.post-74536421583523272122013-03-13T01:06:00.001-07:002013-03-13T01:12:27.099-07:00ASUHAN KEPERAWATAN KLIEN DENGAN CIDERA KEPALA (NANDA NOC NIC) <h3 class="post-title entry-title" itemprop="name" style="text-align: center;">
ASUHAN KEPERAWATAN KLIEN DENGAN CIDERA KEPALA (NANDA,, NOC, NIC) </h3>
<br />
<div class="Section1">
<b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;"></span></b><b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">A.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></b><b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Pengertian</span></b> <br />
<div class="MsoNormal" style="line-height: 150%; margin-left: 14.2pt; text-align: justify; text-indent: .5in;">
<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Cidera kepala adalah pukulan atau benturan mendadak pada kepala dengan atau tanpa kehilangan kesadaran (Tucker, 1998).</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 14.2pt; text-align: justify; text-indent: .5in;">
<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Cidera kepala (terbuka dan tertutup) terdiri dari fraktur tengkorak, commusio (gegar) serebri, contusio (memar) serebri, laserasi dan perdarahan serebral yaitu diantaranya subdural, epidural, intraserebral, dan batang otak (Doenges, 2000:270).</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 14.2pt; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Cidera kepala diklasifikasikan berdasarkan:</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 28.35pt; mso-list: l4 level1 lfo2; tab-stops: list 28.35pt; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Keadaan kulit kepala dan tulang tengkorak</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 42.55pt; mso-list: l4 level2 lfo2; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Cidera kepala terbuka</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 42.55pt; mso-list: l4 level2 lfo2; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Cidera kepala tertutup</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 28.35pt; mso-list: l4 level1 lfo2; tab-stops: list 28.35pt; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Cidera pada jaringan otak (secara anatomis)</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 42.55pt; mso-list: l4 level2 lfo2; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Commusio serebri (gegar otak)</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 42.55pt; mso-list: l4 level2 lfo2; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Edema serebri</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 42.55pt; mso-list: l4 level2 lfo2; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Contusio serebri (memar otak)</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 42.55pt; mso-list: l4 level2 lfo2; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Laserasi</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 56.7pt; mso-list: l4 level3 lfo2; tab-stops: list 56.7pt; text-align: justify; text-indent: -14.15pt;">
<span style="mso-list: Ignore;">1).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Hematoma epidural</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 56.7pt; mso-list: l4 level3 lfo2; tab-stops: list 56.7pt; text-align: justify; text-indent: -14.15pt;">
<span style="mso-list: Ignore;">2).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Hematoma subdural</span></div>
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<span style="mso-list: Ignore;">3).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Perdarahan sub arakhnoid</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 14.2pt; text-align: justify; text-indent: 14.15pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">(Ergan, 1998:642)</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Adanya penetrasi durameter (secara mekanisme)</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 42.55pt; mso-list: l4 level2 lfo2; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Cidera tumpul</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 56.7pt; mso-list: l4 level3 lfo2; tab-stops: list 56.7pt; text-align: justify; text-indent: -14.15pt;">
<span style="mso-list: Ignore;">1).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Kecepatan tinggi (tabrakan otomobil)</span></div>
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<span style="mso-list: Ignore;">2).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Kecepatan rendah (terjatuh, dipukul)</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Cidera tembus</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Luka tembus peluru dan cidera tembus lainnya</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Tingkat keparahan cidera (berdasarkan GCS)</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Cidera Kepala Ringan (CKR) GCS 13-15</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Cidera Kepala Sedang (CKS) GCS 9-12</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Cidera Kepala Berat (CKB) GCS 3-8</span></div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">GCS (Glasgow Coma Scale)</span></b></div>
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<tr style="height: 384.95pt; mso-yfti-firstrow: yes; mso-yfti-irow: 0; mso-yfti-lastrow: yes;"> <td style="height: 384.95pt; padding: 0in 5.4pt 0in 5.4pt; width: 284.6pt;" valign="top" width="379"><div class="MsoNormal" style="line-height: 150%; margin-left: .6pt; text-indent: -.6pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Membuka mata (E)</span></div>
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<span style="font-family: Wingdings; font-size: 11.0pt; line-height: 150%; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Spontan<span style="mso-tab-count: 4;"> </span> </span></div>
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<span style="font-family: Wingdings; font-size: 11.0pt; line-height: 150%; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Dipanggil/diperintah<span style="mso-tab-count: 3;"> </span></span></div>
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<span style="font-family: Wingdings; font-size: 11.0pt; line-height: 150%; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Tekanan pada jari/rangsang nyeri<span style="mso-tab-count: 1;"> </span></span></div>
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<span style="font-family: Wingdings; font-size: 11.0pt; line-height: 150%; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Tidak berespon <span style="mso-tab-count: 1;"> </span></span></div>
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</div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Respon Verbal (V)</span></div>
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<span style="font-family: Wingdings; font-size: 11.0pt; line-height: 150%; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Orientasi baik: dapat bercakap-cakap<span style="mso-tab-count: 1;"> </span></span></div>
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<span style="font-family: Wingdings; font-size: 11.0pt; line-height: 150%; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Bingung, dapat bercakap tapi disorientasi</span></div>
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<span style="font-family: Wingdings; font-size: 11.0pt; line-height: 150%; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Kata yang diucapkan tidak tepat, kacau</span></div>
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<span style="font-family: Wingdings; font-size: 11.0pt; line-height: 150%; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Tidak dapat dimengerti, mengerang<span style="mso-tab-count: 1;"> </span></span></div>
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<span style="font-family: Wingdings; font-size: 11.0pt; line-height: 150%; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Tidak bersuara dengan rangsang nyeri</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Respon Motorik</span></div>
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<span style="font-family: Wingdings; font-size: 11.0pt; line-height: 150%; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Mematuhi perintah<span style="mso-tab-count: 2;"> </span></span></div>
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<span style="font-family: Wingdings; font-size: 11.0pt; line-height: 150%; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Menunjuk lokasi nyeri<span style="mso-tab-count: 2;"> </span></span></div>
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<span style="font-family: Wingdings; font-size: 11.0pt; line-height: 150%; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Reaksi fleksi<span style="mso-tab-count: 4;"> </span></span></div>
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<span style="font-family: Wingdings; font-size: 11.0pt; line-height: 150%; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Fleksi abnormal thdp nyeri (postur dekortikasi)<span style="mso-tab-count: 1;"> </span></span></div>
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<span style="font-family: Wingdings; font-size: 11.0pt; line-height: 150%; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Ekstensi abnormal<span style="mso-tab-count: 5;"> </span><span style="mso-spacerun: yes;"> </span></span></div>
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<span style="font-family: Wingdings; font-size: 11.0pt; line-height: 150%; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Tidak ada respon, flacid<span style="mso-tab-count: 4;"> </span></span></div>
</td> <td style="height: 384.95pt; padding: 0in 5.4pt 0in 5.4pt; width: 160.25pt;" valign="top" width="214"><div class="MsoNormal" style="line-height: 150%; text-align: justify;">
</div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">4</span></b></div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">3</span></b></div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">2</span></b></div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">2</span></b></div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">5</span></b></div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">4</span></b></div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">3</span></b></div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">2</span></b></div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">1</span></b></div>
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</div>
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</div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">6</span></b></div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">5</span></b></div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">4</span></b></div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">3</span></b></div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">2</span></b></div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">1</span></b></div>
</td> </tr>
</tbody></table>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Berdasarkan morfologi</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Fraktur tengkorak</span></div>
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<span style="mso-list: Ignore;">1).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Kranium: linear/ stelatum, depresi/ non depresi, terbuka/ tertutup.</span></div>
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<span style="mso-list: Ignore;">2).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Basis: dengan/ tanpa kebocoran cairan cerebrospinal, dengan/ tanpa kelumpuhan nervus VIII</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Lesi intra cranial</span></div>
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<span style="mso-list: Ignore;">1).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Foxal: epidural, subdural, intraserebral</span></div>
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<span style="mso-list: Ignore;">2).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Difus: konkusi ringan/ klasik, cidera aksonal difus.</span></div>
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</div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">B.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></b><b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Etiologi</span></b></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Cidera kepala merupakan salah satu penyebab kematian dan kecacatan utama pada kelompok usia produktif dan sebagian besar terjadi akibat kecelakaan lalu lintas ( Mansjoer, 2000:3).</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Penyebab cidera kepala antara lain: kecelakaan lalu lintas, perkelahian, terjatuh, dan cidera olah raga. Cidera kepala terbuka sering disebabkan oleh peluru atau pisau (Corkrin, 2001:175).</span></div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">C.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></b><b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Patofisiologi</span></b></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Cidera kepala dapat terjadi karena benturan benda keras, cidera kulit kepala, tulang kepala, jaringan otak, baik terpisah maupun seluruhnya.</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Cidera bervariasi dari luka kulit yang sederhana sampai gegar otak, luka terbuka dari tengkotak, disertai kerusakan otak, cidera pada otak, bisa berasal dari trauma langsung maupun tidak langsung pada kepala.</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Trauma tak langsung disebabkan karena tingginya tahanan atau kekuatan yang merobek terkena pada kepala akibat menarik leher.</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Trauma langsung bila kepala langsung terbuka, semua itu akibat terjadinya akselerasi, deselerasi, dan pembentukan rongga, dilepaskannya gas merusak jaringan syaraf.</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Trauma langsung juga menyebabkan rotasi tengkorak dan isinya. Kerusakan itu bisa terjadi seketika atau menyusul rusaknya otak oleh kompresi, goresan, atau tekanan.</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Cidera yang terjadi waktu benturan mungkin karena memar pada permukaan otak, laserasi substansia alba, cidera robekan, atau hemmorarghi.</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Sebagai akibat, cidera skunder dapat terjadi sebagai kemampuan auto regulasi serebral dikurangi atau tidak ada pada area cidera, konsekuensinya meliputi hiperemia (peningkatan volume darah, peningkatan permeabilitas kapiler, serta vasodilatasi arterial, tekanan intra cranial) (Huddak & Gallo, 1990:226).</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Pengaruh umum cidera kepala juga bisa menyebabkan kram, adanya penumpukan cairan yang berlebihan pada jaringan otak, edema otak akan menyebabkan peningkatan tekanan intra cranial yang dapat menyebabkan herniasi dan penekanan pada batang otak (Price and Wilson, 1995:1010).</span></div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">D.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></b><b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Manifestasi Klinik</span></b></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Berdasarkan anatomis</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Gegar otak (comutio selebri)</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Disfungsi neurologis sementara dapat pulih dengan atau tanpa kehilangan kesadaran</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Pingsan kurang dari 10 menit atau mungkin hanya beberapa detik/menit</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Sakit kepala, tidak mampu konsentrasi, vertigo, mungkin muntah</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Kadang amnesia retrogard</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Edema serebri</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Pingsan lebih dari 10 menit</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Tidak ada kerusakan jaringan otak</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Nyeri kepala, vertigo, muntah</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Memar otak (kontusio selebri)</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Pecahnya pembuluh darah kapiler, tanda dan gejalanya bervariasi tergantung lokasi dan derajad</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Ptechie dan rusaknya jaringan saraf disertai perdarahan</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Peningkatan tekanan intracranial (PTIK)</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Penekanan batang otak</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">e.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Penurunan kesadaran</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">f.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Edema jaringan otak</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">g.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Defisit neurologis</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">h.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Herniasi</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Laserasi</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Hematoma Epidural</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">“talk dan die” tanda klasik: penurunan kesadaran ringan saat benturan, merupakan periode lucid (pikiran jernih), beberapa menit s.d beberapa jam, menyebabkan penurunan kesadaran dan defisit neurologis (tanda hernia):</span></div>
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<span style="mso-list: Ignore;">1).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">kacau mental → koma</span></div>
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<span style="mso-list: Ignore;">2).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">gerakan bertujuan → tubuh dekortikasi atau deseverbrasi</span></div>
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<span style="mso-list: Ignore;">3).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">pupil isokhor → anisokhor</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Hematoma subdural</span></div>
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<span style="mso-list: Ignore;">1).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Akumulasi darah di bawah lapisan duramater diatas arachnoid, biasanya karena aselerasi, deselerasi, pada lansia, alkoholik.</span></div>
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<span style="mso-list: Ignore;">2).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Perdarahan besar menimbulkan gejala-gejala seperti perdarahan epidura</span></div>
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<span style="mso-list: Ignore;">3).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Defisit neurologis dapat timbul berminggu-minggu sampai dengan berbulan-bulan</span></div>
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<span style="mso-list: Ignore;">4).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Gejala biasanya 24-48 jam post trauma (akut)</span></div>
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<span style="mso-list: Ignore;">5).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">perluasan massa lesi</span></div>
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<span style="mso-list: Ignore;">6).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">peningkatan TIK</span></div>
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<span style="mso-list: Ignore;">7).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">sakit kepala, lethargi, kacau mental, kejang</span></div>
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<span style="mso-list: Ignore;">8).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">disfasia</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Perdarahan sub arachnoid</span></div>
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<span style="mso-list: Ignore;">1).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Nyeri kepala hebat</span></div>
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<span style="mso-list: Ignore;">2).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Kaku kuduk</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Berdasarkan nilai GCS (Glasgow Coma Scale)</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Cidera kepala Ringan (CKR)</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">GCS 13-15</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Kehilangan kesadaran/amnesia <30 menit="" span=""><!--30--><!--30--><!--30--></30></span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Tidak ada fraktur tengkorak</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Tidak ada kontusio celebral, hematoma</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Cidera Kepala Sedang (CKS)<span style="mso-tab-count: 1;"> </span></span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">GCS 9-12</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Kehilangan kesadaran dan atau amnesia >30 menit tetapi kurang dari 24 jam</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Dapat mengalami fraktur tengkorak</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Cidera Kepala Berat (CKB)</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">GCS 3-8</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Kehilangan kesadaran dan atau terjadi amnesia > 24 jam </span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Juga meliputi kontusio celebral, laserasi, atau hematoma intracranial (Hudak dan Gallo, 1996:226)</span></div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">E.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></b><b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Komplikasi</span></b></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Kemunduran pada kondisi pasien mungkin karena perluasan hematoma intrakranial, edema serebral progresif, dan herniasi otak</span></div>
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<i><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Edema serebral dan herniasi</span></i></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Edema serebral adalah penyebab paling umum peningkatan TIK pada pasien yang mendapat cedera kepala, puncak pembengkakan yang terjadi kira kira 72 jam setelah cedera. TIK meningkat karena ketidakmampuan tengkorak untuk membesar meskipun peningkatan volume oleh pembengkakan otak diakibatkan trauma.</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Sebagai akibat dari edema dan peningkatan TIK, tekanan disebarkan pada jaringan otak dan struktur internal otak yang kaku. Bergantung pada tempat pembengkakan, perubahan posisi kebawah atau lateral otak (herniasi) melalui atau terhadap struktur kaku yang terjadi menimbulkan iskemia, infark, dan kerusakan otak irreversible, kematian.</span></div>
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<i><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Defisit neurologik dan psikologik</span></i></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Pasien cedera kepala dapat mengalami paralysis saraf fokal seperti anosmia (tidak dapat mencium bau bauan) atau abnormalitas gerakan mata, dan defisit neurologik seperti afasia, defek memori, dan kejang post traumatic atau epilepsy. Pasien mengalami sisa penurunan psikologis organic (melawan, emosi labil) tidak punya malu, emosi agresif dan konsekuensi gangguan.</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Komplikasi lain secara traumatik:</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Infeksi sitemik (pneumonia, ISK, sepsis)</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Infeksi bedah neurologi (infeksi luka, osteomielitis, meningitis, ventikulitis, abses otak)</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Osifikasi heterotropik (nyeri tulang pada sendi sendi)</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Komplikasi lain:</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Peningkatan TIK</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Hemorarghi</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Kegagalan nafas</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Diseksi ekstrakranial</span></div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">F.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></b><b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Penatalaksanaan</span></b></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Penatalaksanaan Keperawatan</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Menjamin kelancaran jalan nafas dan control vertebra cervicalis</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Menjaga saluran nafas tetap bersih, bebas dari secret</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Mempertahankan sirkulasi stabil</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Melakukan observasi tingkat kesadaran dan tanda tanda vital</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">e.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Menjaga intake cairan elektrolit dan nutrisi jangan sampai terjadi hiperhidrasi</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">f.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Menjaga kebersihan kulit untuk mencegah terjadinya decubitus</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">g.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Mengelola pemberian obat sesuai program</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Penatalaksanaan Medis</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Oksigenasi dan IVFD</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Terapi untuk mengurangi edema serebri (anti edema)</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Dexamethasone 10 mg untuk dosis awal, selanjutnya:</span></div>
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<span style="mso-list: Ignore;">1).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">5 mg/6 jam untuk hari I dan II</span></div>
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<span style="mso-list: Ignore;">2).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">5 mg/8 jam untuk hari III</span></div>
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<span style="mso-list: Ignore;">3).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">5 mg/12 jam untuk hari IV</span></div>
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<span style="mso-list: Ignore;">4).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">5 mg/24 jam untuk hari V</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Terapi neurotropik: citicoline, piroxicam</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Terapi anti perdarahan bila perlu</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">e.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Terapi antibiotik untuk profilaksis</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">f.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Terapi antipeuretik bila demam</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">g.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Terapi anti konvulsi bila klien kejang</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">h.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Terapi diazepam 5-10 mg atau CPZ bila klien gelisah</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">i.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Intake cairan tidak boleh > 800 cc/24 jam selama 3-4 hari</span></div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">G.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></b><b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Pemeriksaan Diagnostik</span></b></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">X Ray tengkorak</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">CT Scan</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Angiografi</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Pemeriksaan neurologist</span></div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">H.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></b><b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Asuhan Keperawatan CKS</span></b></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Pengkajian</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Data fokus yang perlu dikaji:</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Riwayat kesehatan meliputi: keluhan utama, kapan cidera terjadi, penyebab cidera, riwayat tak sadar, amnesia, riwayat kesehatan yang lalu, dan riwayat kesehatan keluarga.</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Pemeriksaan fisik</span></div>
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<span style="mso-list: Ignore;">1).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Keadaan umum</span></div>
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<span style="mso-list: Ignore;">2).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Pemeriksaan persistem</span></div>
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<span style="mso-list: Ignore;">a).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Sistem persepsi dan sensori (pemeriksaan panca indera: penglihatan, pendengaran, penciuman, pengecap, dan perasa)</span></div>
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<span style="mso-list: Ignore;">b).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Sistem persarafan (tingkat kesadaran/ nilai GCS, reflek bicara, pupil, orientasi waktu dan tempat)</span></div>
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<span style="mso-list: Ignore;">c).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Sistem pernafasan (nilai frekuensi nafas, kualitas, suara, dan kepatenan jalan nafas)</span></div>
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<span style="mso-list: Ignore;">d).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Sistem kardiovaskuler (nilai TD, nadi dan irama, kualitas, dan frekuensi)</span></div>
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<span style="mso-list: Ignore;">e).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Sistem gastrointestinal (nilai kemampuan menelan, nafsu makan/ minum, peristaltik, eliminasi)</span></div>
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<span style="mso-list: Ignore;">f).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Sistem integumen ( nilai warna, turgor, tekstur dari kulit, luka/ lesi)</span></div>
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<span style="mso-list: Ignore;">g).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Sistem reproduksi</span></div>
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<span style="mso-list: Ignore;">h).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Sistem perkemihan (nilai frekuensi b.a.k, volume b.a.k)</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Pola fungsi kesehatan</span></div>
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<span style="mso-list: Ignore;">1).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Pola persepsi dan pemeliharaan kesehatan (termasuk adakah kebiasaan merokok, minum alcohol, dan penggunaan obat obatan)</span></div>
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<span style="mso-list: Ignore;">2).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Pola aktivitas dan latihan (adakah keluhan lemas, pusing, kelelahan, dan kelemahan otot)</span></div>
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<span style="mso-list: Ignore;">3).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Pola nutrisi dan metabolisme (adakah keluhan mual, muntah)</span></div>
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<span style="mso-list: Ignore;">4).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Pola eliminasi</span></div>
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<span style="mso-list: Ignore;">5).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Pola tidur dan istirahat</span></div>
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<span style="mso-list: Ignore;">6).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Pola kognitif dan perceptual</span></div>
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<span style="mso-list: Ignore;">7).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Persepsi diri dan konsep diri</span></div>
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<span style="mso-list: Ignore;">8).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Pola toleransi dan koping stress</span></div>
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<span style="mso-list: Ignore;">9).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Pola seksual dan reproduktif</span></div>
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<span style="mso-list: Ignore;">10).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Pola hubungan dan peran</span></div>
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<span style="mso-list: Ignore;">11).<span style="font: 7.0pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Pola nilai dan keyakinan</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Diagnosa Keperawatan</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Diagnosa keperawatan yang mungkin muncul pada klien dengan cidera kepala adalah sebagai berikut:</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">1)<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Perfusi jaringan tidak efektif (spesifik serebral) berhubungan dengan aliran arteri dan atau vena terputus.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 46.35pt; mso-list: l26 level2 lfo11; tab-stops: list 46.35pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">2)<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Nyeri akut berhubungan dengan agen injury fisik.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 46.35pt; mso-list: l26 level2 lfo11; tab-stops: list 46.35pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">3)<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Hipertermi berhubungan dengan trauma (cidera jaringan otak, kerusakan batang otak)</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">4)<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Pola nafas tak efektif berhubungan dengan hipoventilasi</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">5)<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Kerusakan persepsi sensori berhubungan dengan penurunan kemampuan kognitif, afektif, dan motorik)</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 46.35pt; mso-list: l26 level2 lfo11; tab-stops: list 46.35pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">6)<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Kerusakan mobilitas fisik berhubungan dengan penurunan kemampuan kognitif, motorik, dan afektif.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 46.35pt; mso-list: l26 level2 lfo11; tab-stops: list 46.35pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">7)<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Defisit perawatan diri: makan/ mandi, toileting berhubungan dengan kelemahan fisik dan nyeri.</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">8)<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Kurang pengetahuan berhubungan dengan penurunan kemampuan kognitif, motorik, dan afektif.</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">9)<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Resiko aspirasi berhubungan dengan penurunan tingkat kesadaran.</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">10)<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Resiko kekurangan volume cairan berhubungan dengan status hipermetabolik.</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">11)<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Resiko tinggi infeksi berhubungan dengan trauma/ laserasi kulit kepala</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">12)<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">Resiko tinggi terhadap perubahan nutrisi: kurang dari kebutuhan tubuh berhubungan dengan mual, muntah.</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">13)<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">PK: peningkatan TIK dengan proses desak ruang akibat penumpukan cairan/ darah di dalam otak.</span></div>
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</div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">3. Rencana Perawatan </span></b></div>
<div align="center">
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<b><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">No</span></b></div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Diagnosa</span></b></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<b><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Keperawatan<span style="mso-spacerun: yes;"> </span></span></b></div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Tujuan dan kriteria hasil</span></b></div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Intervensi</span></b></div>
</td> </tr>
<tr style="mso-yfti-irow: 1;"> <td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt;" valign="top"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">1</span></div>
</td> <td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 109.9pt;" valign="top" width="147"><div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Perfusi jaringan tak efektif (spesifik sere-bral) b.d aliran arteri dan atau vena terputus, dengan batasan karak-teristik:</span></div>
<div class="MsoNormal" style="margin-left: .25in; mso-list: l21 level1 lfo28; tab-stops: list .25in; text-align: justify; text-indent: -.25in;">
<span style="font-size: 10.0pt;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Perubahan respon motorik</span></div>
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<span style="font-size: 10.0pt;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Perubahan status mental</span></div>
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<span style="font-size: 10.0pt;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Perubahan respon pupil</span></div>
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<span style="font-size: 10.0pt;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Amnesia retrograde (gang-guan memori)</span></div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">NOC:</span></b></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Status sirkulasi</span></div>
<div class="MsoNormal" style="margin-left: 14.2pt; mso-list: l23 level1 lfo21; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Perfusi jaringan serebral</span></div>
<div class="MsoNormal" style="text-align: justify;">
</div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Setelah dilakukan tindakan keperawatan selama ….x 24 jam, klien mampu men-capai :</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Status sirkulasi dengan indikator:</span></div>
<div class="MsoNormal" style="margin-left: 28.35pt; mso-list: l9 level3 lfo23; tab-stops: list 28.35pt; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Tekanan darah sis-tolik dan diastolik dalam rentang yang diharapkan</span></div>
<div class="MsoNormal" style="margin-left: 28.35pt; mso-list: l9 level3 lfo23; tab-stops: list 28.35pt; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Tidak ada ortostatik hipotensi</span></div>
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<span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Tidak ada tanda tan-da PTIK</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Perfusi jaringan serebral, dengan indicator :</span></div>
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<span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Klien mampu berko-munikasi dengan je-las dan sesuai ke-mampuan</span></div>
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<span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Klien menunjukkan perhatian, konsen-trasi, dan orientasi</span></div>
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<span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Klien mampu mem-proses informasi</span></div>
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<span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Klien mampu mem-buat keputusan de-ngan benar</span></div>
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<span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Tingkat kesadaran klien membaik</span></div>
<div class="MsoNormal">
</div>
</td> <td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 209.65pt;" valign="top" width="280"><div class="MsoNormal">
<b><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Monitor Tekanan Intra Kranial</span></b></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Catat perubahan respon klien terhadap stimu-lus / rangsangan</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Monitor TIK klien dan respon neurologis terhadap aktivitas</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Monitor intake dan output</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Pasang restrain, jika perlu</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Monitor suhu dan angka leukosit</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Kaji adanya kaku kuduk</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">7.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Kelola pemberian antibiotik</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">8.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Berikan posisi dengan kepala elevasi 30-40<sup>O</sup> dengan leher dalam posisi netral</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">9.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Minimalkan stimulus dari lingkungan</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">10.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Beri jarak antar tindakan keperawatan untuk meminimalkan peningkatan TIK</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">11.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Kelola obat obat untuk mempertahankan TIK dalam batas spesifik</span></div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Monitoring Neurologis (2620)</span></b></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Monitor ukuran, kesimetrisan, reaksi dan bentuk pupil</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Monitor tingkat kesadaran klien</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Monitor tanda-tanda vital</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Monitor keluhan nyeri kepala, mual, dan muntah</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Monitor respon klien terhadap pengobatan</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Hindari aktivitas jika TIK meningkat</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">7.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Observasi kondisi fisik klien</span></div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Terapi Oksigen (3320)</span></b></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Bersihkan jalan nafas dari secret</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Pertahankan jalan nafas tetap efektif</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Berikan oksigen sesuai instruksi</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Monitor aliran oksigen, kanul oksigen, dan humidifier</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Beri penjelasan kepada klien tentang pentingnya pemberian oksigen</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Observasi tanda-tanda hipoventilasi</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">7.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Monitor respon klien terhadap pemberian oksigen</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">8.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Anjurkan klien untuk tetap memakai oksigen selama aktivitas dan tidur</span></div>
</td> </tr>
<tr style="mso-yfti-irow: 2;"> <td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt;" valign="top"><div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; line-height: 150%;">2</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Nyeri akut b.d dengan agen injuri fisik, dengan batasan karakteristik:</span></div>
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<span style="font-size: 10.0pt;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Laporan nyeri ke-pala secara verbal atau non verbal</span></div>
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<span style="font-size: 10.0pt;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Respon autonom (perubahan vital sign, dilatasi pupil)</span></div>
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<span style="font-size: 10.0pt;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Tingkah laku eks-presif (gelisah, me-nangis, merintih)</span></div>
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<span style="font-size: 10.0pt;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Fakta dari observasi</span></div>
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<span style="font-size: 10.0pt;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Gangguan tidur (mata sayu, menye-ringai, dll)</span></div>
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<b><span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL;">NOC:</span></b></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Nyeri terkontrol</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Tingkat Nyeri</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Tingkat kenyamanan</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Setelah dilakukan asuhan keperawatan selama …. x 24 jam, klien dapat :</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Mengontrol nyeri, de-ngan indikator:</span></div>
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<span style="font-size: 10.0pt;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Mengenal faktor-faktor penyebab</span></div>
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<span style="font-size: 10.0pt;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Mengenal onset nyeri</span></div>
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<span style="font-size: 10.0pt;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Tindakan pertolong-an non farmakologi</span></div>
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<span style="font-size: 10.0pt;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Menggunakan anal-getik</span></div>
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<span style="font-size: 10.0pt;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Melaporkan gejala-gejala nyeri kepada tim kesehatan.</span></div>
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<span style="font-size: 10.0pt;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Nyeri terkontrol</span></div>
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</div>
<div class="MsoNormal" style="margin-left: 12.6pt; mso-list: l6 level1 lfo12; tab-stops: list 12.6pt; text-align: justify; text-indent: -12.6pt;">
<span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL;">Menunjukkan tingkat nyeri, dengan indikator:</span></div>
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<span style="font-size: 10.0pt;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Melaporkan nyeri</span></div>
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<span style="font-size: 10.0pt;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Frekuensi nyeri</span></div>
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<span style="font-size: 10.0pt;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Lamanya episode nyeri</span></div>
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<span style="font-size: 10.0pt;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Ekspresi nyeri; wa-jah</span></div>
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<span style="font-size: 10.0pt;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Perubahan respirasi rate</span></div>
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<span style="font-size: 10.0pt;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Perubahan tekanan darah</span></div>
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<span style="font-size: 10.0pt;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Kehilangan nafsu makan</span></div>
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</div>
<div class="MsoNormal" style="margin-left: 14.2pt; mso-list: l23 level2 lfo21; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Tingkat kenyamanan, dengan indicator :</span></div>
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<span style="font-size: 10.0pt;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Klien melaporkan kebutuhan tidur dan istirahat tercukupi</span></div>
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</td> <td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 209.65pt;" valign="top" width="280"><div class="MsoNormal" style="text-align: justify;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Manajemen nyeri (1400) </span></b></div>
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<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Kaji keluhan nyeri, lokasi, karakteristik, onset/durasi, frekuensi, kualitas, dan beratnya nyeri.</span></div>
<div class="MsoNormal" style="margin-left: 14.2pt; mso-list: l29 level2 lfo13; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Observasi respon ketidaknyamanan secara verbal dan non verbal.</span></div>
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<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Pastikan klien menerima perawatan analgetik dg tepat.</span></div>
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<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Gunakan strategi komunikasi yang efektif untuk mengetahui respon penerimaan klien terhadap nyeri.</span></div>
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<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Evaluasi keefektifan penggunaan kontrol nyeri </span></div>
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<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Monitoring perubahan nyeri baik aktual maupun potensial.</span></div>
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<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">7.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Sediakan lingkungan yang nyaman.</span></div>
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<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">8.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Kurangi faktor-faktor yang dapat menambah ungkapan nyeri.</span></div>
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<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">9.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Ajarkan penggunaan tehnik relaksasi sebelum atau sesudah nyeri berlangsung.</span></div>
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<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">10.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Kolaborasi dengan tim kesehatan lain untuk memilih tindakan selain obat untuk meringankan nyeri.</span></div>
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<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">11.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Tingkatkan istirahat yang adekuat untuk meringankan nyeri.</span></div>
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<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;"><span style="mso-spacerun: yes;"> </span><b>Manajemen pengobatan (2380)</b></span></div>
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<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Tentukan obat yang dibutuhkan klien dan cara mengelola sesuai dengan anjuran/ dosis.</span></div>
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<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Monitor efek teraupetik dari pengobatan.</span></div>
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<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Monitor tanda, gejala dan efek samping obat.</span></div>
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<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Monitor interaksi obat.</span></div>
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<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Ajarkan pada klien / keluarga cara mengatasi efek samping pengobatan.</span></div>
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<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Jelaskan manfaat pengobatan yg dapat mempengaruhi gaya hidup klien.</span></div>
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<b><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;"><span style="mso-spacerun: yes;"> </span>Pengelolaan analgetik</span></b><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;"> <b>(2210)</b></span></div>
<div class="MsoNormal" style="margin-left: 14.2pt; mso-list: l36 level1 lfo18; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Periksa perintah medis tentang obat, dosis & frekuensi obat analgetik.</span></div>
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<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Periksa riwayat alergi klien.</span></div>
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<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Pilih obat berdasarkan tipe dan beratnya nyeri.</span></div>
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<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Pilih cara pemberian IV atau IM untuk pengobatan, jika mungkin.</span></div>
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<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Monitor vital sign sebelum dan sesudah pemberian analgetik. </span></div>
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<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Kelola jadwal pemberian analgetik yang sesuai. </span></div>
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<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">7.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Evaluasi efektifitas dosis analgetik, observasi tanda dan gejala efek samping, misal depresi pernafasan, mual dan muntah, mulut kering, & konstipasi.</span></div>
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<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">8.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Kolaborasi dgn dokter untuk obat, dosis & cara pemberian yg diindikasikan.</span></div>
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<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">9.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Tentukan lokasi nyeri, karakteristik, kualitas, dan keparahan sebelum pengobatan.</span></div>
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<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">10.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Berikan obat dengan prinsip 5 benar</span></div>
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<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">11.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Dokumentasikan respon dari analgetik dan efek yang tidak diinginkan</span></div>
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<tr style="mso-yfti-irow: 3;"> <td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt;" valign="top"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">3</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Defisit self care b.d de-ngan kelelahan,<span style="mso-spacerun: yes;"> </span>nyeri</span></div>
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</td> <td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 125.6pt;" valign="top" width="167"><div class="MsoBodyText3" style="margin-left: 32.0pt; text-indent: -32.0pt;">
<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10.0pt;">NOC:</span></div>
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<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10.0pt;">Perawatan diri</span><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10.0pt; font-weight: normal;"> : </span></div>
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<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10.0pt; font-weight: normal;">(mandi, Makan Toiletting, berpakaian)</span></div>
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</div>
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<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10.0pt;">Setelah diberi motivasi perawatan selama ….x24<span style="mso-spacerun: yes;"> </span>jam, ps mengerti cara memenuhi ADL secara bertahap sesuai kemam-puan, dengan kriteria :</span><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10.0pt; font-weight: normal;"></span></div>
<div class="MsoNormal" style="margin-left: 11.35pt; mso-list: l31 level1 lfo26; tab-stops: list 11.35pt; text-align: justify; text-indent: -11.35pt;">
<span lang="NL" style="color: #333333; font-family: Symbol; font-size: 10.0pt; mso-ansi-language: NL; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL;">Mengerti secara seder-hana cara<span style="mso-spacerun: yes;"> </span>mandi, makan, toileting, dan berpakaian serta mau mencoba se-cara aman tanpa cemas</span></div>
<div class="MsoNormal" style="margin-left: 11.35pt; mso-list: l31 level1 lfo26; tab-stops: list 11.35pt; text-align: justify; text-indent: -11.35pt;">
<span lang="NL" style="color: #333333; font-family: Symbol; font-size: 10.0pt; mso-ansi-language: NL; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL;">Klien mau berpartisipasi dengan senang hati tanpa keluhan dalam memenuhi ADL</span></div>
</td> <td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 209.65pt;" valign="top" width="280"><h5 style="margin-left: 24.25pt; mso-outline-level: 5; text-align: justify; text-indent: -24.25pt;">
<span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 10.0pt;">NIC: Membantu perawatan diri klien Mandi <span style="mso-spacerun: yes;"> </span>dan toiletting</span></h5>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Aktifitas:</span></div>
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<span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL;">Tempatkan alat-alat mandi di tempat yang mudah dikenali dan mudah dijangkau klien</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Libatkan klien dan dampingi</span></div>
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<span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL;">Berikan bantuan selama klien masih mampu mengerjakan sendiri</span></div>
<h6 style="mso-outline-level: 6; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">NIC: ADL Berpakaian</span></h6>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Aktifitas:</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Informasikan pada klien dalam memilih pakaian selama perawatan</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Sediakan pakaian di tempat yang mudah dijangkau</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Bantu berpakaian yang sesuai</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Jaga privcy klien</span></div>
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<span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL;">Berikan pakaian pribadi yg digemari dan sesuai</span></div>
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</div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">NIC: ADL Makan</span></b></div>
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<span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL;">Anjurkan duduk dan berdo’a bersama teman</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Dampingi saat makan</span></div>
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<span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL;">Bantu jika klien belum mampu dan beri contoh</span></div>
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<span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL;">Beri rasa nyaman saat makan</span></div>
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<tr style="mso-yfti-irow: 4; mso-yfti-lastrow: yes;"> <td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt;" valign="top"><div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; line-height: 150%;">4</span></div>
</td> <td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 109.9pt;" valign="top" width="147"><div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">PK: peningkatan tekan-an intrakranial b.d pro-ses desak ruang akibat penumpukan cairan / darah di dalam otak (Carpenito, 1999)</span></div>
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</div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Batasan karakteristik :</span></b></div>
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<span style="font-size: 10.0pt;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Penurunan kesadar-an (gelisah, disori-entasi)</span></div>
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<span style="font-size: 10.0pt;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Perubahan motorik dan persepsi sensasi</span></div>
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<span style="font-size: 10.0pt;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Perubahan tanda vi-tal (TD meningkat, nadi kuat dan lambat)</span></div>
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<span style="font-size: 10.0pt;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Pupil melebar, re-flek pupil menurun</span></div>
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<span style="font-size: 10.0pt;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Muntah</span></div>
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<span style="font-size: 10.0pt;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Klien mengeluh mual</span></div>
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<span style="font-size: 10.0pt;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Klien mengeluh pandangan kabur dan diplopia</span></div>
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<span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL;">Setelah dilakukan tindakan keperawatan selama ....x 24 jam dapat mencegah atau meminimalkan komplikasi dari peningkatan TIK, dengan kriteria :</span></div>
<div class="MsoNormal" style="margin-left: 11.35pt; mso-list: l28 level1 lfo25; tab-stops: list 11.35pt; text-align: justify; text-indent: -11.35pt;">
<span lang="NL" style="font-family: Symbol; font-size: 10.0pt; mso-ansi-language: NL; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL;">Kesadaran stabil (orien-asi baik)</span></div>
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<span lang="NL" style="font-family: Symbol; font-size: 10.0pt; mso-ansi-language: NL; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL;">Pupil isokor, diameter 1mm</span></div>
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<span lang="NL" style="font-family: Symbol; font-size: 10.0pt; mso-ansi-language: NL; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL;">Reflek baik</span></div>
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<span lang="NL" style="font-family: Symbol; font-size: 10.0pt; mso-ansi-language: NL; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL;">Tidak mual</span></div>
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<span lang="NL" style="font-family: Symbol; font-size: 10.0pt; mso-ansi-language: NL; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: NL;">Tidak muntah</span></div>
</td> <td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 209.65pt;" valign="top" width="280"><div class="MsoNormal" style="margin-left: 14.2pt; mso-list: l33 level1 lfo16; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Pantau tanda dan gejala peningkatan TIK</span></div>
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<span lang="SV" style="font-family: Wingdings; font-size: 10.0pt; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Kaji respon membuka mata, respon motorik, dan verbal, (GCS)</span></div>
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<span lang="SV" style="font-family: Wingdings; font-size: 10.0pt; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Kaji perubahan tanda-tanda vital</span></div>
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<span lang="SV" style="font-family: Wingdings; font-size: 10.0pt; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Kaji respon pupil</span></div>
<div class="MsoNormal" style="margin-left: 28.35pt; mso-list: l33 level2 lfo16; tab-stops: list 28.35pt; text-align: justify; text-indent: -14.15pt;">
<span lang="SV" style="font-family: Wingdings; font-size: 10.0pt; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Catat gejala dan tanda-tanda: muntah, sakit kepala, lethargi, gelisah, nafas keras, gerakan tak bertujuan, perubahan mental</span></div>
<div class="MsoNormal" style="margin-left: 14.2pt; mso-list: l33 level1 lfo16; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Tinggikan kepala 30-40<sup>O </sup>jika tidak ada kontra indikasi</span></div>
<div class="MsoNormal" style="margin-left: 14.2pt; mso-list: l33 level1 lfo16; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Hindarkan situasi atau manuver sebagai berikut:</span></div>
<div class="MsoNormal" style="margin-left: 28.35pt; mso-list: l33 level2 lfo16; tab-stops: list 28.35pt; text-align: justify; text-indent: -14.15pt;">
<span lang="SV" style="font-family: Wingdings; font-size: 10.0pt; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Masase karotis</span></div>
<div class="MsoNormal" style="margin-left: 28.35pt; mso-list: l33 level2 lfo16; tab-stops: list 28.35pt; text-align: justify; text-indent: -14.15pt;">
<span lang="SV" style="font-family: Wingdings; font-size: 10.0pt; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Fleksi dan rotasi leher berlebihan</span></div>
<div class="MsoNormal" style="margin-left: 28.35pt; mso-list: l33 level2 lfo16; tab-stops: list 28.35pt; text-align: justify; text-indent: -14.15pt;">
<span lang="SV" style="font-family: Wingdings; font-size: 10.0pt; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Stimulasi anal dengan jari, menahan nafas, dan mengejan</span></div>
<div class="MsoNormal" style="margin-left: 28.35pt; mso-list: l33 level2 lfo16; tab-stops: list 28.35pt; text-align: justify; text-indent: -14.15pt;">
<span lang="SV" style="font-family: Wingdings; font-size: 10.0pt; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Perubahan posisi yang cepat</span></div>
<div class="MsoNormal" style="margin-left: 14.2pt; mso-list: l33 level1 lfo16; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Ajarkan klien untuk ekspirasi selama perubahan posisi</span></div>
<div class="MsoNormal" style="margin-left: 14.2pt; mso-list: l33 level1 lfo16; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Konsul dengan dokter untuk pemberian pe-lunak faeces, jika perlu</span></div>
<div class="MsoNormal" style="margin-left: 14.2pt; mso-list: l33 level1 lfo16; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Pertahankan lingkungan yang tenang</span></div>
<div class="MsoNormal" style="margin-left: 14.2pt; mso-list: l33 level1 lfo16; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">7.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Hindarkan pelaksanaan urutan aktivitas yang dapat meningkatkan TIK (misal: batuk, penghisapan, pengubahan posisi, meman-dikan)</span></div>
<div class="MsoNormal" style="margin-left: 14.2pt; mso-list: l33 level1 lfo16; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">8.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Batasi waktu penghisapan pada tiap waktu hingga 10 detik</span></div>
<div class="MsoNormal" style="margin-left: 14.2pt; mso-list: l33 level1 lfo16; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">9.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Hiperoksigenasi dan hiperventilasi klien se-belum dan sesudah penghisapan</span></div>
<div class="MsoNormal" style="margin-left: 14.2pt; mso-list: l33 level1 lfo16; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">10.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Konsultasi dengan dokter tentang pemberian lidokain profilaktik sebelum penghisapan</span></div>
<div class="MsoNormal" style="margin-left: 14.2pt; mso-list: l33 level1 lfo16; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">11.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Pertahankan ventilasi optimal melalui posisi yang sesuai dan penghisapan yang teratur</span></div>
<div class="MsoNormal" style="margin-left: 14.2pt; mso-list: l33 level1 lfo16; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">12.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Jika diindikasikan, lakukan protokol atau kolaborasi dengan dokter untuk terapi obat yang mungkin termasuk sebagai berikut:</span></div>
<div class="MsoNormal" style="margin-left: 14.2pt; mso-list: l33 level1 lfo16; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">13.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Sedasi, barbiturat (menurunkan laju meta-bolisme serebral)</span></div>
<div class="MsoNormal" style="margin-left: 14.2pt; mso-list: l33 level1 lfo16; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">14.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Antikonvulsan (mencegah kejang)</span></div>
<div class="MsoNormal" style="margin-left: 14.2pt; mso-list: l33 level1 lfo16; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">15.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Diuretik osmotik (menurunkan edema serebral)</span></div>
<div class="MsoNormal" style="margin-left: 14.2pt; mso-list: l33 level1 lfo16; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">16.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Diuretik non osmotik (mengurangi edema serebral)</span></div>
<div class="MsoNormal" style="margin-left: 14.2pt; mso-list: l33 level1 lfo16; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">17.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Steroid (menurunkan permeabilitas kapiler, membatasi edema serebral)</span></div>
<div class="MsoNormal" style="margin-left: 14.2pt; mso-list: l33 level1 lfo16; tab-stops: list 14.2pt; text-align: justify; text-indent: -14.2pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">18.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-ansi-language: SV;">Pantau status hidrasi, evaluasi cairan masuk dan keluar)</span></div>
</td> </tr>
</tbody></table>
</div>
</div>
<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%; mso-ansi-language: EN-US; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;"><br clear="all" style="mso-break-type: section-break; page-break-before: always;" /> </span> <br />
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b><span style="font-family: "Arial","sans-serif"; font-size: 11.0pt; line-height: 150%;">DAFTAR PUSTAKA</span></b></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
</div>
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</div>
<div class="MsoNormal" style="margin-left: .5in; text-align: justify; text-indent: -.5in;">
<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt;">Brunner dan Suddarth. 2001. <i>Buku Ajar Keperawatan Medikal Bedah. </i>Volume II. Edisi 8. Jakarta: Penerbit Buku Kedokteran EGC.</span></div>
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</div>
<div class="MsoNormal" style="margin-left: .5in; text-align: justify; text-indent: -.5in;">
<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt;">Carpenito, L.J. 1999. <i>Rencana Asuhan dan Dokumentasi Keperawatan dan Masalah Kolaborasi</i>. Edisi 8. Jakarta: Penerbit Buku Kedokteran EGC.</span></div>
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</div>
<div class="MsoNormal" style="margin-left: .5in; text-align: justify; text-indent: -.5in;">
<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt;">Doenges, M.E. 1999. <i>Rencana Asuhan Keperawatan</i>. Edisi 3. Jakarta: Penerbit Buku Kedokteran EGC.</span></div>
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</div>
<div class="MsoNormal" style="margin-left: .5in; text-align: justify; text-indent: -.5in;">
<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt;">Hudak dan Gallo. 1996. <i>Keperawatan Kritis Pendekatan Holistik</i>. Volume II. Edisi 6. Jakarta: Penerbit Buku Kedokteran EGC.</span></div>
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</div>
<div class="MsoNormal" style="margin-left: .5in; text-align: justify; text-indent: -.5in;">
<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt;">Marion Johnson, dkk. 2000. <i>Nursing Outcomes Classification (NOC) Second</i> <i>Edition</i>. Mosby.</span></div>
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</div>
<div class="MsoNormal" style="margin-left: .5in; text-align: justify; text-indent: -.5in;">
<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt;">Mc. Closkey dan Buleccheck. 2000. <i>Nursing Interventions Classification (NIC) Second Edition</i>. Mosby.</span></div>
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</div>
<div class="MsoNormal" style="margin-left: .5in; text-align: justify; text-indent: -.5in;">
<span style="font-family: "Arial","sans-serif"; font-size: 11.0pt;">NANDA. 2005. <i>Nursing Diagnosis: Definition and Classification</i>. Philadelphia: North American Nursing Diagnosis Association.</span></div>
ERFANSYAH. HRhttp://www.blogger.com/profile/07497970584312798191noreply@blogger.com0tag:blogger.com,1999:blog-2228299828902052163.post-29888638702506548112013-03-11T09:54:00.001-07:002013-03-11T10:04:17.517-07:00Animasi Jalan LahirAnimasi Jalan Lahir<br />
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<br />ERFANSYAH. HRhttp://www.blogger.com/profile/07497970584312798191noreply@blogger.com0tag:blogger.com,1999:blog-2228299828902052163.post-26845681768941543202013-01-21T14:25:00.001-08:002013-03-11T09:57:14.865-07:00FORMAT PENGKAJIAN ASUHAN KEPERAWATAN INTRA NATAL KEPERAWATAN MATERNITAS<!--[if gte mso 9]><xml>
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<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">FORMAT
PENGKAJIAN ASUHAN KEPERAWATAN INTRA NATAL</span></b></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">KEPERAWATAN
MATERNITAS</span></b></div>
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<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Nama Mahasiswa<span style="mso-tab-count: 1;"> </span>: </span></div>
<div class="MsoNormal" style="text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">NIM<span style="mso-tab-count: 3;"> </span>:
</span></div>
<div class="MsoNormal">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Tempat Praktek<span style="mso-tab-count: 1;"> </span>:</span></div>
<div class="MsoNormal">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Tanggal<span style="mso-tab-count: 2;"> </span>:<span style="mso-spacerun: yes;"> </span></span></div>
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<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;"><span> </span>Pengkajian<span style="mso-tab-count: 1;"> </span>:<span style="mso-tab-count: 3;"> </span><span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal">
<span lang="SV" style="font-family: "Arial","sans-serif";">Praktik<span style="mso-tab-count: 1;"> </span>:</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 27.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level1 lfo1; text-indent: -27.0pt;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">I.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">IDENTITAS PASIEN</span></b></div>
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<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Nama<span style="mso-tab-count: 3;"> </span>:
......................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Umur<span style="mso-tab-count: 3;"> </span>:
......................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Status Perkawinan<span style="mso-tab-count: 1;"> </span>:
......................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Agama<span style="mso-tab-count: 3;"> </span>:
......................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Suku<span style="mso-tab-count: 3;"> </span>:
......................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt;">
<span lang="IT" style="font-family: "Arial","sans-serif"; mso-ansi-language: IT;">Pendidikan<span style="mso-tab-count: 2;"> </span>:
......................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt;">
<span lang="IT" style="font-family: "Arial","sans-serif"; mso-ansi-language: IT;">Nama Suami<span style="mso-tab-count: 2;"> </span>:
......................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt;">
<span lang="IT" style="font-family: "Arial","sans-serif"; mso-ansi-language: IT;">Umur Suami<span style="mso-tab-count: 2;"> </span>:
......................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Alamat<span style="mso-tab-count: 3;"> </span>:
......................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Pekerjaan<span style="mso-tab-count: 2;"> </span>:
......................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Diagnosa Medis<span style="mso-tab-count: 2;"> </span>:
......................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Tanggal Masuk RS<span style="mso-tab-count: 1;"> </span>:
......................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 27.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level1 lfo1; text-indent: -27.0pt;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">II.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">DATA KESEHATAN</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level2 lfo1; text-indent: -18.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">TB<span style="mso-tab-count: 1;"> </span>:..............cm;<span style="mso-tab-count: 2;"> </span>BB<span style="mso-tab-count: 1;"> </span>: (sekarang<span style="mso-tab-count: 2;"> </span>:......kg)</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 216.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;"><span style="mso-spacerun: yes;"> </span>(sebelum hamil<span style="mso-tab-count: 1;"> </span>:......kg)</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level2 lfo1; text-indent: -18.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Masalah kesehatan khusus</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 45.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">..............................................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level2 lfo1; text-indent: -18.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;"><span style="mso-spacerun: yes;"> </span>Obat-obatan yang
dikonsumsi</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 45.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">..............................................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level2 lfo1; text-indent: -18.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Riwayat alergi, sebutkan :</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 45.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">.............................................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level2 lfo1; text-indent: -18.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">e.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Diet khusus</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 45.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">..............................................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level2 lfo1; text-indent: -18.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">f.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;"><span style="mso-spacerun: yes;"> </span>Penggunaan alat
bantu</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 45.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">..............................................................................................................................
BAB<span style="mso-tab-count: 1;"> </span>:.............x/hari, masalah :
......................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level2 lfo1; text-indent: -18.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">g.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">BAK<span style="mso-tab-count: 1;"> </span>:.............x/hari,
masalah : ......................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level2 lfo1; text-indent: -18.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">h.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;"><span style="mso-spacerun: yes;"> </span>Kebiasaan waktu
tidur</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 45.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">..............................................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 27.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level1 lfo1; text-indent: -27.0pt;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">III.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">DATA MATERNITAS</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Kehamilan sekarang direncanakan<span style="mso-tab-count: 1;"> </span>: ya / tidak</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">G...P...A...</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;"><span style="mso-spacerun: yes;"> </span>UK
:............................HPMT : ..............................HPL
:.................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Data anak :</span></div>
<table border="1" cellpadding="0" cellspacing="0" class="MsoTableGrid" style="border-collapse: collapse; border: none; margin-left: -7.2pt; mso-border-alt: solid windowtext .5pt; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-table-layout-alt: fixed; mso-yfti-tbllook: 480; width: 578px;">
<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td style="border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 21.95pt;" width="29">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 8.0pt; line-height: 150%; mso-ansi-language: SV;">No</span></b></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 46.1pt;" width="61">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 8.0pt; line-height: 150%; mso-ansi-language: SV;">Jenis Kelamin</span></b></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 46.1pt;" width="61">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 8.0pt; line-height: 150%; mso-ansi-language: SV;">Cara Lahir</span></b></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 55.3pt;" width="74">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 8.0pt; line-height: 150%; mso-ansi-language: SV;">Penolong Persalinan</span></b></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 55.3pt;" width="74">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 8.0pt; line-height: 150%; mso-ansi-language: SV;">Tempat Persalinan</span></b></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 45.95pt;" width="61">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 8.0pt; line-height: 150%; mso-ansi-language: SV;">BB lahir</span></b></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 78.2pt;" width="104">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 8.0pt; line-height: 150%; mso-ansi-language: SV;">Masalah selama persalinan</span></b></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 48.35pt;" width="64">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 8.0pt; line-height: 150%; mso-ansi-language: SV;">Keadaan sekarang</span></b></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 36.15pt;" width="48">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; font-size: 8.0pt; line-height: 150%; mso-ansi-language: SV;">Umur</span></b></div>
</td>
</tr>
<tr style="mso-yfti-irow: 1; mso-yfti-lastrow: yes;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 21.95pt;" width="29">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 46.1pt;" width="61">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 46.1pt;" width="61">
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 55.3pt;" width="74">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 55.3pt;" width="74">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 45.95pt;" width="61">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 78.2pt;" width="104">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 48.35pt;" width="64">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 36.15pt;" width="48">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span lang="ES" style="font-family: "Arial","sans-serif"; mso-ansi-language: ES; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">e.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="ES" style="font-family: "Arial","sans-serif"; mso-ansi-language: ES;">Mengikuti antenatal care<span style="mso-tab-count: 1;"> </span>:
ya / tidak,.........kali</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span lang="FI" style="font-family: "Arial","sans-serif"; mso-ansi-language: FI; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">f.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="ES" style="font-family: "Arial","sans-serif"; mso-ansi-language: ES;"><span style="mso-spacerun: yes;"> </span></span><span lang="FI" style="font-family: "Arial","sans-serif"; mso-ansi-language: FI;">Masalah
kehamilan / persalinan yang lalu :
...........................................................................................................................................................................................................................................................................................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">g.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Masalah kehamilan sekarang :</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 45.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Trimester I<span style="mso-tab-count: 1;"> </span>: ..................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 45.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Trimester II<span style="mso-tab-count: 1;"> </span>:
..................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 45.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Trimester III<span style="mso-tab-count: 1;"> </span>: ..................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">h.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Kontrasepsi yang pernah dipakai dan masalah yang timbul :
..............................................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span lang="FI" style="font-family: "Arial","sans-serif"; mso-ansi-language: FI; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">i.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="font-family: "Arial","sans-serif"; mso-ansi-language: FI;"><span style="mso-spacerun: yes;"> </span>Rencana KB
setelah kehamilan ini :
..............................................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span lang="FI" style="font-family: "Arial","sans-serif"; mso-ansi-language: FI; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">j.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="font-family: "Arial","sans-serif"; mso-ansi-language: FI;"><span style="mso-spacerun: yes;"> </span>Makanan bayi
sebelumnya : ASI ekslusif / PASI sejak umur..........................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 45.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">sebutkan jenisnya
:
........................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">k.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;"><span style="mso-spacerun: yes;"> </span>Pendidikan
kesehatan yang ingin didapatkan selama perawatan : cara menyusui / perawatan
payudara / perawatan perineum / senam nifas / kontrasepsi / lainnya, sebutkan :
.........................................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l0 level1 lfo2; text-indent: -18.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">l.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;"><span style="mso-spacerun: yes;"> </span>Yang diharapkan
membantu selama kelahiran bayi ini : suami / orang tua / lainnya, sebutkan :
..........................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 27.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level1 lfo1; text-indent: -27.0pt;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">IV.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">RIWAYAT PERSALINAN SEKARANG</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l3 level1 lfo3; text-indent: -18.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Mulai kontraksi, tanggal ...........................jam
..................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l3 level1 lfo3; text-indent: -18.0pt;">
<span lang="FI" style="font-family: "Arial","sans-serif"; mso-ansi-language: FI; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="font-family: "Arial","sans-serif"; mso-ansi-language: FI;">Kontraksi saat ini : ..........x/menit, kekuatan :
.................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l3 level1 lfo3; text-indent: -18.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="font-family: "Arial","sans-serif"; mso-ansi-language: FI;"><span style="mso-spacerun: yes;"> </span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Mulai
pengeluaran per vaginam, tanggal : .........................jam :
....................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 45.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">berupa :
..........................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l3 level1 lfo3; text-indent: -18.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">DJJ : ..............x/menit, kekuatan :
..................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l3 level1 lfo3; text-indent: -18.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">e.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">TB : .........cm, BB : (sekarang) :..........kg</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 108.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;"><span style="mso-spacerun: yes;"> </span>(sebelum hamil) : .........kg</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l3 level1 lfo3; text-indent: -18.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">f.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;"><span style="mso-spacerun: yes;"> </span>BP<span style="mso-tab-count: 1;"> </span>: ........mmHg, P : ......x/menit, R :
......x/menit, T : .......</span><span lang="SV" style="font-family: Symbol; mso-ansi-language: SV; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-char-type: symbol; mso-hansi-font-family: Arial; mso-symbol-font-family: Symbol;"><span style="mso-char-type: symbol; mso-symbol-font-family: Symbol;">°</span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">C</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l3 level1 lfo3; text-indent: -18.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">g.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Ekstremitas : edema / tidak</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l3 level1 lfo3; text-indent: -18.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">h.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Pemeriksaan dalam</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 45.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Jam<span style="mso-tab-count: 1;"> </span>:
..............................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 45.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Oleh<span style="mso-tab-count: 1;"> </span>:
..............................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 45.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Hasil<span style="mso-tab-count: 1;"> </span>:
..............................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 45.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Ketuban : utuh /
pecah, pecah tanggal .............................Jam.......................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 45.0pt;">
<span lang="EN-US" style="font-family: "Arial","sans-serif";">Warna..............................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l3 level1 lfo3; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">i.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="font-family: "Arial","sans-serif";"><span style="mso-spacerun: yes;"> </span>Pemeriksaan penunjang</span></div>
<table border="1" cellpadding="0" cellspacing="0" class="MsoTableGrid" style="border-collapse: collapse; border: none; mso-border-alt: solid windowtext .5pt; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-yfti-tbllook: 480;">
<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td style="border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.55pt;" width="142">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="EN-US" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; line-height: 150%;">Hari/Tanggal/Jam</span></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.55pt;" width="142">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="EN-US" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; line-height: 150%;">Jenis
Terapi</span></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.55pt;" width="142">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="EN-US" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; line-height: 150%;">Hasil</span></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.6pt;" width="142">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="EN-US" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; line-height: 150%;">Interpretasi</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 1; mso-yfti-lastrow: yes;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.55pt;" valign="top" width="142">
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.55pt;" valign="top" width="142">
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.55pt;" valign="top" width="142">
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 106.6pt;" valign="top" width="142">
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l3 level1 lfo3; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">j.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="font-family: "Arial","sans-serif";">Terapi
yang diberikan</span></div>
<table border="1" cellpadding="0" cellspacing="0" class="MsoTableGrid" style="border-collapse: collapse; border: none; mso-border-alt: solid windowtext .5pt; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-yfti-tbllook: 480;">
<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td style="border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 85.25pt;" valign="top" width="114">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="EN-US" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; line-height: 150%;">Hari/Tanggal/Jam</span></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 85.25pt;" valign="top" width="114">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="EN-US" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; line-height: 150%;">Jenis
Terapi</span></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 85.25pt;" valign="top" width="114">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="EN-US" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; line-height: 150%;">Rute
Pemberian</span></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 85.25pt;" valign="top" width="114">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="EN-US" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; line-height: 150%;">Dosis</span></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 85.25pt;" valign="top" width="114">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="EN-US" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; line-height: 150%;">Indikasi</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 1; mso-yfti-lastrow: yes;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 85.25pt;" valign="top" width="114">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 85.25pt;" valign="top" width="114">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 85.25pt;" valign="top" width="114">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 85.25pt;" valign="top" width="114">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 85.25pt;" valign="top" width="114">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level1 lfo1; text-indent: -18.0pt;">
<b><span lang="EN-US" style="font-family: "Arial","sans-serif"; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">V.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b><span lang="EN-US" style="font-family: "Arial","sans-serif";">DATA
PSIKOSOSIAL</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 36.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l2 level1 lfo4; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="font-family: "Arial","sans-serif";">Penghasilan
keluarga / bulan : Rp………………………………………………….</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 36.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l2 level1 lfo4; text-indent: -18.0pt;">
<span lang="FI" style="font-family: Symbol; mso-ansi-language: FI; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="font-family: "Arial","sans-serif"; mso-ansi-language: FI;">Perasaan ibu tentang kehamilan ini
………………………………………………………………………………………….…</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 36.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l2 level1 lfo4; text-indent: -18.0pt;">
<span lang="FI" style="font-family: Symbol; mso-ansi-language: FI; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="FI" style="font-family: "Arial","sans-serif"; mso-ansi-language: FI;">Perasaan pasangan tentang kehamilan ini
.................................................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 36.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l2 level1 lfo4; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Symbol; mso-ansi-language: SV; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Respon sibling terhadap kehamilan ini
.................................................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level1 lfo1; text-indent: -18.0pt;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">VI.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">DATA PERSALINAN</span></b></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">KALA I</span></b></div>
<table border="1" cellpadding="0" cellspacing="0" class="MsoTableGrid" style="border-collapse: collapse; border: none; mso-border-alt: solid windowtext .5pt; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-yfti-tbllook: 480;">
<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td style="border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 104.4pt;" width="139">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Hari/tanggal</span></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 99.0pt;" width="132">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Jam</span></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 222.85pt;" width="297">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Hasil
Observasi</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 1; mso-yfti-lastrow: yes;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 104.4pt;" valign="top" width="139">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 99.0pt;" valign="top" width="132">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 222.85pt;" valign="top" width="297">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Data bayi baru lahir :</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Hari/tanggal lahir<span style="mso-tab-count: 1;"> </span>: ..................................<span style="mso-tab-count: 1;"> </span>Jam<span style="mso-tab-count: 2;"> </span>:
...........................</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Jenis kelamin<span style="mso-tab-count: 2;"> </span>: ..................................<span style="mso-tab-count: 1;"> </span>Lingkar kepala<span style="mso-tab-count: 1;"> </span>: ...........................</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Berat badan<span style="mso-tab-count: 2;"> </span>: ..................................<span style="mso-tab-count: 1;"> </span>Lingkar dada<span style="mso-tab-count: 1;"> </span>: ...........................</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Panjang badan<span style="mso-tab-count: 1;"> </span>: ..................................<span style="mso-tab-count: 1;"> </span></span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">APGAR score<span style="mso-tab-count: 2;"> </span>:</span></div>
<table border="1" cellpadding="0" cellspacing="0" class="MsoTableGrid" style="border-collapse: collapse; border: none; mso-border-alt: solid windowtext .5pt; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-yfti-tbllook: 480;">
<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td style="border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 24.9pt;" width="33">
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">No</span></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 70.5pt;" width="94">
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Tgl / jam</span></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 160.35pt;" width="214">
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Karakteristik
yang dinilai</span></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 85.25pt;" width="114">
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Menit ke 1</span></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 85.25pt;" width="114">
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Menit ke 5</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 1;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 24.9pt;" width="33">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 70.5pt;" width="94">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 160.35pt;" width="214">
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Denyut jantung</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 85.25pt;" width="114">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 85.25pt;" width="114">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
</tr>
<tr style="mso-yfti-irow: 2;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 24.9pt;" width="33">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 70.5pt;" width="94">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 160.35pt;" width="214">
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Pernafasan</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 85.25pt;" width="114">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 85.25pt;" width="114">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
</tr>
<tr style="mso-yfti-irow: 3;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 24.9pt;" width="33">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 70.5pt;" width="94">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 160.35pt;" width="214">
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Refleks</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 85.25pt;" width="114">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 85.25pt;" width="114">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
</tr>
<tr style="mso-yfti-irow: 4;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 24.9pt;" width="33">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 70.5pt;" width="94">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 160.35pt;" width="214">
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Tonus otot</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 85.25pt;" width="114">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 85.25pt;" width="114">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
</tr>
<tr style="mso-yfti-irow: 5;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 24.9pt;" width="33">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 70.5pt;" width="94">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 160.35pt;" width="214">
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Warna kulit</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 85.25pt;" width="114">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 85.25pt;" width="114">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
</tr>
<tr style="mso-yfti-irow: 6; mso-yfti-lastrow: yes;">
<td colspan="3" style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 255.75pt;" width="341">
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Jumlah total</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 85.25pt;" width="114">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 85.25pt;" width="114">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Kesimpulan :
..........................................................................................................................................................................................................................................................................................</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">KALA III</span></b></div>
<table border="1" cellpadding="0" cellspacing="0" class="MsoTableGrid" style="border-collapse: collapse; border: none; mso-border-alt: solid windowtext .5pt; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-yfti-tbllook: 480;">
<tbody>
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ERFANSYAH. HRhttp://www.blogger.com/profile/07497970584312798191noreply@blogger.com0tag:blogger.com,1999:blog-2228299828902052163.post-23208202888955247902013-01-21T14:12:00.007-08:002013-03-11T09:57:14.863-07:00FORMAT PENGKAJIAN ASUHAN KEPERAWATAN PRE NATAL KEPERAWATAN MATERNITAS <!--[if gte mso 9]><xml>
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<b><span lang="FI" style="font-family: "Arial","sans-serif"; mso-ansi-language: FI;">FORMAT
PENGKAJIAN ASUHAN KEPERAWATAN PRE NATAL</span></b></div>
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<b><span lang="FI" style="font-family: "Arial","sans-serif"; mso-ansi-language: FI;">KEPERAWATAN
MATERNITAS</span></b></div>
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<br /></div>
<div class="MsoNormal" style="line-height: normal;">
<span lang="FI" style="font-family: "Arial","sans-serif"; mso-ansi-language: FI;">Nama Mahasiswa<span style="mso-tab-count: 1;"> </span>: </span></div>
<div class="MsoNormal" style="line-height: normal;">
<span lang="FI" style="font-family: "Arial","sans-serif"; mso-ansi-language: FI;">NIM<span style="mso-tab-count: 3;"> </span>:
</span></div>
<div class="MsoNormal" style="line-height: normal;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Tempat Praktek<span style="mso-tab-count: 1;"> </span>:</span></div>
<div class="MsoNormal" style="line-height: normal;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Tanggal<span style="mso-tab-count: 2;"> </span>:<span style="mso-spacerun: yes;">
</span>Pengkajian<span style="mso-tab-count: 1;"> </span>:<span style="mso-tab-count: 1;"> </span></span></div>
<div class="MsoNormal" style="line-height: normal;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;"><span style="mso-tab-count: 3;"> </span><span style="mso-spacerun: yes;"> </span>Praktik<span style="mso-tab-count: 1;"> </span>:</span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 27.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l0 level1 lfo1; text-indent: -27.0pt;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">I.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">IDENTITAS PASIEN</span></b></div>
<div class="MsoNormal" style="line-height: normal; margin-left: 27.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Nama<span style="mso-tab-count: 3;"> </span>:
......................................................................................</span></div>
<div class="MsoNormal" style="line-height: normal; margin-left: 27.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Umur<span style="mso-tab-count: 3;"> </span>: ......................................................................................</span></div>
<div class="MsoNormal" style="line-height: normal; margin-left: 27.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Status Perkawinan<span style="mso-tab-count: 1;"> </span>:
......................................................................................</span></div>
<div class="MsoNormal" style="line-height: normal; margin-left: 27.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Agama<span style="mso-tab-count: 3;"> </span>:
......................................................................................</span></div>
<div class="MsoNormal" style="line-height: normal; margin-left: 27.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Suku<span style="mso-tab-count: 3;"> </span>:
......................................................................................</span></div>
<div class="MsoNormal" style="line-height: normal; margin-left: 27.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Pendidikan<span style="mso-tab-count: 2;"> </span>:
......................................................................................</span></div>
<div class="MsoNormal" style="line-height: normal; margin-left: 27.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Nama Suami<span style="mso-tab-count: 2;"> </span>: ......................................................................................</span></div>
<div class="MsoNormal" style="line-height: normal; margin-left: 27.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Umur Suami<span style="mso-tab-count: 2;"> </span>:
......................................................................................</span></div>
<div class="MsoNormal" style="line-height: normal; margin-left: 27.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Alamat<span style="mso-tab-count: 3;"> </span>:
......................................................................................</span></div>
<div class="MsoNormal" style="line-height: normal; margin-left: 27.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Pekerjaan<span style="mso-tab-count: 2;"> </span>:
......................................................................................</span></div>
<div class="MsoNormal" style="line-height: normal; margin-left: 27.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Diagnosa Medis<span style="mso-tab-count: 2;"> </span>:
......................................................................................</span></div>
<div class="MsoNormal" style="line-height: normal; margin-left: 27.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Tanggal Masuk RS<span style="mso-tab-count: 1;"> </span>: ......................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 27.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l0 level1 lfo1; text-indent: -27.0pt;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">II.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">KELUHAN UTAMA</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">....................................................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 27.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l0 level1 lfo1; text-indent: -27.0pt;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">III.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">RIWAYAT PENYAKIT DAHULU</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">....................................................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 27.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l0 level1 lfo1; text-indent: -27.0pt;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">IV.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">RIWAYAT PENYAKIT KELUARGA</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">....................................................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 27.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l0 level1 lfo1; text-indent: -27.0pt;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">V.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">RIWAYAT GINEKOLOGI</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">....................................................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 27.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l0 level1 lfo1; text-indent: -27.0pt;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">VI.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">RIWAYAT OBSTETRI</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level1 lfo2; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Menarche usia<span style="mso-tab-count: 1;"> </span>:
......................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level1 lfo2; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Siklus Menstruasi<span style="mso-tab-count: 1;"> </span>:
teratur/ tidak,............hari.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level1 lfo2; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Karakteristik mens<span style="mso-tab-count: 1;"> </span>:
......................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level1 lfo2; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">G.....P.....A.....</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level1 lfo2; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">HPMT<span style="mso-tab-count: 3;"> </span>:
......................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level1 lfo2; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">HPL<span style="mso-tab-count: 3;"> </span>:
......................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level1 lfo2; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Keluhan selama kehamilan ini</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 36.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Trimester I<span style="mso-tab-count: 1;"> </span>:
..................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 36.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Trimester II<span style="mso-tab-count: 1;"> </span>:
..................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 36.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Trimester III<span style="mso-tab-count: 1;"> </span>:
..................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 27.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l0 level1 lfo1; text-indent: -27.0pt;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">VII.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">KEBIASAAN YANG MERUGIKAN</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Merokok<span style="mso-tab-count: 2;"> </span>[<span style="mso-spacerun: yes;"> </span>]<span style="mso-tab-count: 2;"> </span>Obat-obat
terlarang<span style="mso-tab-count: 2;"> </span>[<span style="mso-spacerun: yes;"> </span>]</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Alkohol<span style="mso-tab-count: 2;"> </span>[<span style="mso-spacerun: yes;"> </span>]<span style="mso-tab-count: 2;"> </span>Obat-obat
yang dijual bebas<span style="mso-tab-count: 1;"> </span>[<span style="mso-spacerun: yes;"> </span>]</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 27.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l0 level1 lfo1; text-indent: -27.0pt;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">VIII.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></b><b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">KELUARGA
BERENCANA</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">....................................................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 27.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l0 level1 lfo1; text-indent: -27.0pt;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">IX.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">KEBUTUHAN DASAR MANUSIA</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level1 lfo2; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">NUTRISI</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 36.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">................................................................................................................................. </span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 36pt;">
<span lang="SV" style="font-family: "Arial","sans-serif";">ELIMINASI</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 36.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">.................................................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level1 lfo2; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">ISTIRAHAT DAN TIDUR</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 36.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">.................................................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level1 lfo2; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">SEKSUALITAS</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 36.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">.................................................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level1 lfo2; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">PERSEPSI DAN KOGNITIF</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 36.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">.................................................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 36pt;">
<span lang="SV" style="font-family: "Arial","sans-serif";"> KONSEP DIRI</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 27.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l0 level1 lfo1; text-indent: -27.0pt;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">X.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">PEMERIKSAAN FISIK</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Keadaan Umum</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level1 lfo2; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Kesadaran<span style="mso-tab-count: 1;"> </span>:
..................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level1 lfo2; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">BB<span style="mso-tab-count: 2;"> </span>:
.......kg (kenaikan BB selama hamil : ......kg), TB :........m</span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level1 lfo2; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Tanda Vital<span style="mso-tab-count: 1;"> </span>: P<span style="mso-tab-count: 1;"> </span>:.........x/menit<span style="mso-tab-count: 2;"> </span>T<span style="mso-tab-count: 1;"> </span>:
.........</span><span lang="SV" style="font-family: Symbol; mso-ansi-language: SV; mso-ascii-font-family: Arial; mso-bidi-font-family: Arial; mso-char-type: symbol; mso-hansi-font-family: Arial; mso-symbol-font-family: Symbol;"><span style="mso-char-type: symbol; mso-symbol-font-family: Symbol;">°</span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">C</span></div>
<div class="MsoNormal" style="line-height: normal; margin-left: 108.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;"><span style="mso-spacerun: yes;"> </span>R<span style="mso-tab-count: 1;"> </span>:
........x/menit<span style="mso-tab-count: 2;"> </span>BP<span style="mso-tab-count: 1;"> </span>: .........mmHg</span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level1 lfo2; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Kulit</span></div>
<div class="MsoNormal" style="line-height: normal; margin-left: 36.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Linea nigrae<span style="mso-tab-count: 2;"> </span>[<span style="mso-spacerun: yes;"> </span>]<span style="mso-tab-count: 2;"> </span>Cloasma<span style="mso-tab-count: 1;"> </span>[<span style="mso-spacerun: yes;">
</span>]</span></div>
<div class="MsoNormal" style="line-height: normal; margin-left: 36.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Striae gravidarum<span style="mso-tab-count: 1;"> </span>[<span style="mso-spacerun: yes;">
</span>]<span style="mso-tab-count: 2;"> </span>Pucat<span style="mso-tab-count: 2;"> </span>[<span style="mso-spacerun: yes;"> </span>]</span></div>
<div class="MsoNormal" style="line-height: normal; margin-left: 36.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Angioma<span style="mso-tab-count: 2;"> </span>[<span style="mso-spacerun: yes;"> </span>]<span style="mso-tab-count: 2;"> </span>Eritema<span style="mso-tab-count: 1;"> </span>[<span style="mso-spacerun: yes;">
</span>]</span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level1 lfo2; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Kuku dan kaki<span style="mso-tab-count: 2;"> </span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-left: 36.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Oedema<span style="mso-tab-count: 2;"> </span>[<span style="mso-spacerun: yes;"> </span>]</span></div>
<div class="MsoNormal" style="line-height: normal; margin-left: 36.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Lainnya<span style="mso-tab-count: 1;"> </span>: ..................................................................................................</span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level1 lfo2; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Kepala</span></div>
<div class="MsoNormal" style="line-height: normal; margin-left: 36.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Sklera<span style="mso-tab-count: 2;"> </span>:
..................................................................................................</span></div>
<div class="MsoNormal" style="line-height: normal; margin-left: 36.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Konjungtiva<span style="mso-tab-count: 1;"> </span>: ..................................................................................................</span></div>
<div class="MsoNormal" style="line-height: normal; margin-left: 36.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Palpebra<span style="mso-tab-count: 1;"> </span>:
..................................................................................................</span></div>
<div class="MsoNormal" style="line-height: normal; margin-left: 36.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Pembesaran limphe
nodi<span style="mso-tab-count: 1;"> </span>:
...........................................................................</span></div>
<div class="MsoNormal" style="line-height: normal; margin-left: 36.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Pembesaran
kelenjar tiroid<span style="mso-tab-count: 1;"> </span>:
...........................................................................</span></div>
<div class="MsoNormal" style="line-height: normal; margin-left: 36.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Telinga<span style="mso-tab-count: 1;"> </span>:
..................................................................................................</span></div>
<div class="MsoNormal" style="line-height: normal; margin-left: 36.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">THT<span style="mso-tab-count: 2;"> </span>: ..................................................................................................</span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level1 lfo2; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Thoraks</span></div>
<div class="MsoNormal" style="line-height: normal; margin-left: 36.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Jantung<span style="mso-tab-count: 1;"> </span>:
..................................................................................................</span></div>
<div class="MsoNormal" style="line-height: normal; margin-left: 36.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Paru<span style="mso-tab-count: 2;"> </span>:
..................................................................................................</span></div>
<div class="MsoNormal" style="line-height: normal; margin-left: 36.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Payudara<span style="mso-tab-count: 1;"> </span>:
..................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level1 lfo2; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Abdomen</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 36.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">.................................................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level1 lfo2; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Perineum</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 36.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">.................................................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level1 lfo2; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Muskuloskeletal</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 36.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">.................................................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 45.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l1 level1 lfo2; text-indent: -18.0pt;">
<span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">Syaraf</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 36.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">.................................................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 27.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l0 level1 lfo1; text-indent: -27.0pt;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">XI.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">INFORMASI LAIN</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 27.0pt;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">....................................................................................................................................</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 27.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l0 level1 lfo1; text-indent: -27.0pt;">
<b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">XII.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b><span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">ANALISA DATA</span></b></div>
<table border="1" cellpadding="0" cellspacing="0" class="MsoTableGrid" style="border-collapse: collapse; border: none; mso-border-alt: solid windowtext .5pt; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-yfti-tbllook: 480;">
<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td style="border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 185.4pt;" width="247">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">DATA</span></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 126.0pt;" width="168">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">PROBLEM</span></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 114.85pt;" width="153">
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span lang="SV" style="font-family: "Arial","sans-serif"; mso-ansi-language: SV;">ETIOLOGY</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 1; mso-yfti-lastrow: yes;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 185.4pt;" valign="top" width="247">
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 126.0pt;" valign="top" width="168">
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 114.85pt;" valign="top" width="153">
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
ERFANSYAH. HRhttp://www.blogger.com/profile/07497970584312798191noreply@blogger.com0tag:blogger.com,1999:blog-2228299828902052163.post-82856275203921814312013-01-13T06:10:00.007-08:002013-03-11T09:57:14.868-07:00EMPAT DASAR MENGANGKAT PASIEN<!--[if gte mso 9]><xml>
<o:OfficeDocumentSettings>
<o:TargetScreenSize>800x600</o:TargetScreenSize>
</o:OfficeDocumentSettings>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:WordDocument>
<w:View>Normal</w:View>
<w:Zoom>0</w:Zoom>
<w:TrackMoves/>
<w:TrackFormatting/>
<w:PunctuationKerning/>
<w:ValidateAgainstSchemas/>
<w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid>
<w:IgnoreMixedContent>false</w:IgnoreMixedContent>
<w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText>
<w:DoNotPromoteQF/>
<w:LidThemeOther>IN</w:LidThemeOther>
<w:LidThemeAsian>X-NONE</w:LidThemeAsian>
<w:LidThemeComplexScript>X-NONE</w:LidThemeComplexScript>
<w:Compatibility>
<w:BreakWrappedTables/>
<w:SnapToGridInCell/>
<w:WrapTextWithPunct/>
<w:UseAsianBreakRules/>
<w:DontGrowAutofit/>
<w:SplitPgBreakAndParaMark/>
<w:EnableOpenTypeKerning/>
<w:DontFlipMirrorIndents/>
<w:OverrideTableStyleHps/>
</w:Compatibility>
<w:BrowserLevel>MicrosoftInternetExplorer4</w:BrowserLevel>
<m:mathPr>
<m:mathFont m:val="Cambria Math"/>
<m:brkBin m:val="before"/>
<m:brkBinSub m:val="--"/>
<m:smallFrac m:val="off"/>
<m:dispDef/>
<m:lMargin m:val="0"/>
<m:rMargin m:val="0"/>
<m:defJc m:val="centerGroup"/>
<m:wrapIndent m:val="1440"/>
<m:intLim m:val="subSup"/>
<m:naryLim m:val="undOvr"/>
</m:mathPr></w:WordDocument>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:LatentStyles DefLockedState="false" DefUnhideWhenUsed="true"
DefSemiHidden="true" DefQFormat="false" DefPriority="99"
LatentStyleCount="267">
<w:LsdException Locked="false" Priority="0" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Normal"/>
<w:LsdException Locked="false" Priority="9" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="heading 1"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 2"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 3"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 4"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 5"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 6"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 7"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 8"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 9"/>
<w:LsdException Locked="false" Priority="39" Name="toc 1"/>
<w:LsdException Locked="false" Priority="39" Name="toc 2"/>
<w:LsdException Locked="false" Priority="39" Name="toc 3"/>
<w:LsdException Locked="false" Priority="39" Name="toc 4"/>
<w:LsdException Locked="false" Priority="39" Name="toc 5"/>
<w:LsdException Locked="false" Priority="39" Name="toc 6"/>
<w:LsdException Locked="false" Priority="39" Name="toc 7"/>
<w:LsdException Locked="false" Priority="39" Name="toc 8"/>
<w:LsdException Locked="false" Priority="39" Name="toc 9"/>
<w:LsdException Locked="false" Priority="0" Name="header"/>
<w:LsdException Locked="false" Priority="0" Name="footer"/>
<w:LsdException Locked="false" Priority="35" QFormat="true" Name="caption"/>
<w:LsdException Locked="false" Priority="0" Name="page number"/>
<w:LsdException Locked="false" Priority="10" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Title"/>
<w:LsdException Locked="false" Priority="0" Name="Default Paragraph Font"/>
<w:LsdException Locked="false" Priority="11" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Subtitle"/>
<w:LsdException Locked="false" Priority="22" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Strong"/>
<w:LsdException Locked="false" Priority="20" SemiHidden="false"
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<w:LsdException Locked="false" Priority="59" SemiHidden="false"
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<w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid"/>
<w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1"/>
<w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2"/>
<w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1"/>
<w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2"/>
<w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1"/>
<w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2"/>
<w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3"/>
<w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List"/>
<w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading"/>
<w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List"/>
<w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid"/>
<w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 1"/>
<w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 1"/>
<w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 1"/>
<w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 1"/>
<w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 1"/>
<w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 1"/>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Calisto MT","serif";">EMPAT DASAR
MENGANGKAT</span></b></div>
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<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<span lang="EN-US" style="font-family: "Calisto MT","serif";">Sebelum mengangkat objek, perawat
harus memutuskan bahwa objek tersebut dapat diangkat oleh satu orang secara
aman, jika perawat merasa bahwa objek tersebut terlalu berat atau terlalu
besar, perlu meminta bantuan orang lain. Selain itu, perawat harus mengkaji
motivasi klien dan kemampuannya dalam membantu untuk pemindahan atau perubahan
posisi.</span></div>
<ol start="1" style="margin-top: 0cm;" type="1">
<li class="MsoNormal" style="mso-list: l0 level1 lfo2; tab-stops: list 36.0pt; text-align: justify;"><span lang="EN-US" style="font-family: "Calisto MT","serif";">Posisi
berat: berat yang akan diangkat harus sedekat mungkin dengan pengangkat.
Posisi ini menempatkan objek yang akan diangkat dalam level yang sama
dengan pengangkat.</span></li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo2; tab-stops: list 36.0pt; text-align: justify;"><span lang="EN-US" style="font-family: "Calisto MT","serif";">Ketingginan
objek: objek yang paling tinggi untuk diangkat secara vertical adalah
ketinggian 15-20 cm dibawah ukuran pinggang orang yang mengangkat objek.</span></li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo2; tab-stops: list 36.0pt; text-align: justify;"><span lang="EN-US" style="font-family: "Calisto MT","serif";">Posisi
badan: pengangkat harus berposisi bokongnya lurus sehigga kelompok otot
multiple bekerja bersama-sama</span></li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo2; tab-stops: list 36.0pt; text-align: justify;"><span lang="EN-US" style="font-family: "Calisto MT","serif";">Berat
maksimal: objek terlalu berat jika besar lebih dari 25-30% dari tubuh
pengangkat.</span></li>
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<br /></div>
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<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Calisto MT","serif";">LANGKAH:</span></b></div>
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<span lang="SV" style="font-family: "Calisto MT","serif"; mso-ansi-language: SV; mso-bidi-font-family: "Calisto MT"; mso-fareast-font-family: "Calisto MT";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Calisto MT","serif"; mso-ansi-language: SV;">Berdiri dekat objek yang akan dipindahkan sehingga pusat
pengangkat gaya gravitasinya lebih dekat dengan objek.</span></div>
<div class="MsoNormal" style="margin-left: 19.85pt; mso-list: l1 level1 lfo1; tab-stops: list 19.85pt; text-align: justify; text-indent: -19.85pt;">
<span lang="SV" style="font-family: "Calisto MT","serif"; mso-ansi-language: SV; mso-bidi-font-family: "Calisto MT"; mso-fareast-font-family: "Calisto MT";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Calisto MT","serif"; mso-ansi-language: SV;">perbesar dasar penyokong dengan menempatkan kaki secara
terpisah. Cara ini mempertahankan keseimbangan tubuh dengan lebih baik dan
mengurangi resiko jatuh.</span></div>
<div class="MsoNormal" style="margin-left: 19.85pt; mso-list: l1 level1 lfo1; tab-stops: list 19.85pt; text-align: justify; text-indent: -19.85pt;">
<span lang="SV" style="font-family: "Calisto MT","serif"; mso-ansi-language: SV; mso-bidi-font-family: "Calisto MT"; mso-fareast-font-family: "Calisto MT";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Calisto MT","serif"; mso-ansi-language: SV;">turunkan pusat gravitasi anda terhadap objek yang akan
diangkat. Cara ini meningkatkan keseimbangan tubuh dan memugkinkan keklompok
otot untuk bekerja bersama secara sinkron.</span></div>
<div class="MsoNormal" style="margin-left: 19.85pt; mso-list: l1 level1 lfo1; tab-stops: list 19.85pt; text-align: justify; text-indent: -19.85pt;">
<span lang="SV" style="font-family: "Calisto MT","serif"; mso-ansi-language: SV; mso-bidi-font-family: "Calisto MT"; mso-fareast-font-family: "Calisto MT";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="SV" style="font-family: "Calisto MT","serif"; mso-ansi-language: SV;">pertahankan kesejajaran yang baik dari kepala dan leher
dengan tulang belakang, jaga agar bokong tetap lurus, untuk mengurangi risiko
cedera vertebra lumbal dan kelompok otot (Owens, Welden, dan Kane, 1999 dalam
Perry Potter)</span></div>
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<span lang="SV" style="font-family: "Calisto MT","serif";"><span style="mso-spacerun: yes;"> </span></span><span lang="EN-US" style="font-family: "Calisto MT","serif";">(<i style="mso-bidi-font-style: normal;">Sumber; Perry, Peterson, Potter; Buku Saku Keterampilan dan Prosedur
Dasar)</i></span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
ERFANSYAH. HRhttp://www.blogger.com/profile/07497970584312798191noreply@blogger.com0tag:blogger.com,1999:blog-2228299828902052163.post-31305877602711033132013-01-13T06:07:00.005-08:002013-03-11T09:57:14.867-07:00DEKUBITUS<div style="font-family: "Courier New",Courier,monospace;">
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<div align="center" class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: center;">
<b style="mso-bidi-font-weight: normal;">DEKUBITUS</b></div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
PENDAHULUAN</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
Kita kehilangan
sekitar satu gram sel kulit setiap harinya karena gesekan kulit pada baju dan
aktivitas higiene yang dilakukan setiap hari seperti mandi.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
Dekubitus dapat
terjadi pada setiap tahap umur, tetapi hal ini merupakan masalah<span style="mso-spacerun: yes;"> </span>yang khusus pada lansia. Khsusnya pada klien
dengan imobilitas.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
Seseorang yang
tidak im-mobil yang tidak berbaring ditempat tidur sampai berminggu-minggu
tanpa terjadi dekubitus karena dapat berganti posisi beberapa kali dalam sejam.
Penggantian posisi ini, biarpun hanya bergeser, sudah cukup untuk mengganti
bagian tubuh yang kontak dengan alas tempat tidur.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
Sedangkan
im-mobilitas hampir menyebabkan dekubitus bila berlangsung lama. Terjadinya
ulkus disebabkan ganggual aliran darah setempat, dan juga keadaan umum dari
penderita.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
Dekubitus adalah
kerusakan/kematian kulit sampai jaringan dibawah kulit, bahkan menembus otot
sampai mengenai tulang akibat adanya penekanan pada suatu area secara terus
menerus sehingga mengakibatkan gangguan sirkulasi darah setempat.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
Walaupun semua
bagian tubuh mengalami dekubitus, bagian bawah dari tubuhlah yang terutama
beresiko tinggi dan membutuhkan perhatian khsus.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
Area yang biasa
terjadi dekubitus adalah tempat diatas tonjolan tulang dan tidak dilindungi
oleh cukup dengan lemak sub kutan, misalnya daerah sakrum, daerah trokanter
mayor dan spina ischiadica superior anterior, daerah tumit dan siku.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
Dekubitus
merupakan suatu hal yang serius, dengan angka morbiditas dan mortalitas yang
tinggi pada penderita lanjut usia. Dinegara-negara maju, prosentase terjadinya
dekubitus mencapai sekitar 11% dan terjadi dalam dua minggu pertama dalam
perawatan.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
Usia lanjut
mempunyai potensi besar untuk terjadi dekubitus karena perubahan kulit
berkaitan dengan bertambahnya usia antara lain:</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 18pt; text-align: justify; text-indent: -18pt;">
<span style="mso-list: Ignore;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Berkurangnya jaringan lemak subkutan</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 18pt; text-align: justify; text-indent: -18pt;">
<span style="mso-list: Ignore;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Berkurangnya jaringan kolagen dan elastin</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 18pt; text-align: justify; text-indent: -18pt;">
<span style="mso-list: Ignore;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Menurunnya efesiensi kolateral kapiler pada kulit
sehingga kulit menjadi lebih tipis dan rapuh.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
TIPE ULKUS
DEKUBITUS</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
Berdasarkan waktu
yang diperlukan untuk penyembuhan dari suatu ulkus dekubitus dan perbedaan
temperatur dari ulkus dengan kulit sekitarnya, dekubitus dapat dibagi menjadi
tiga;</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 17pt; text-align: justify; text-indent: -17pt;">
<span style="mso-list: Ignore;">1.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Tipe normal</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 17pt; text-align: justify;">
Mempunyai beda
temperatur sampai dibawah lebih kurang 2,5<sup>o</sup>C dibandingkan kulit
sekitarnya dan akan sembuh dalam perawatan sekitar 6 minggu. Ulkus ini terjadi
karena iskemia jaringan setempat akibat tekanan, tetapi aliran darah dan
pembuluh-pembuluh darah sebenarnya baik.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 17pt; text-align: justify; text-indent: -17pt;">
<span style="mso-list: Ignore;">2.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Tipe arterioskelerosis</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 17pt; text-align: justify;">
Mempunyai beda
temperatur kurang dari 1<sup>o</sup>C antara daerah ulkus dengan kulit
sekitarnya. Keadaan ini menunjukkan gangguan aliran darah akibat penyakit pada
pembuluh darah (arterisklerotik) ikut perperan untuk terjadinya dekubitus
disamping faktor tekanan. Dengan perawatan, ulkus ini diharapkan sembuh dalam
16 minggu.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 17pt; text-align: justify; text-indent: -17pt;">
<span style="mso-list: Ignore;">3.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Tipe terminal</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 17pt; text-align: justify;">
Terjadi pada
penderita yang akan meninggal dunia dan tidak akan sembuh.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
PATOFISIOLOGI
TERJADINYA DEKUBITUS</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
Tekanan daerah
pada kapiler berkisar antara 16 mmHg-33 mmHg. Kulit akan tetap utuh karena
sirkulasi darah terjaga, bila tekanan padanya masih berkisar pada batas-batas
tersebut. Tetapi sebagai contoh bila seorang penderita immobil/terpancang pada
tempat tidurnya secara pasif dan berbaring diatas kasur busa maka tekanan
daerah sakrum akan mencapai 60-70 mmHg dan daerah tumit mencapai 30-45 mmHg.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
Tekanan akan
menimbulkan daerah iskemik dan bila berlanjut terjadi nokrosis jaringan kulit.
Percobaan pada binatang didapatkan bahwa sumbatan total pada kapiler masih
bersifat reversibel bila kurang dari 2 jam. Seorang yang terpaksa berbaring
berminggu-minggu tidak akan mengalami dakubitus selama dapat mengganti posisi
beberapa kali perjammnya.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
Selain faktor
tekanan, ada beberapa faktor mekanik tambahan yang dapat memudahkan terjadinya
dekubitus;</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 18pt; text-align: justify; text-indent: -18pt;">
<span style="mso-list: Ignore;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Faktor teregangnya kulit misalnya gerakan meluncur ke
bawah pada penderita dengan posisi dengan setengah berbaring</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 18pt; text-align: justify; text-indent: -18pt;">
<span style="mso-list: Ignore;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Faktor terlipatnya kulit akiab gesekan badan yang sangat
kurus dengan alas tempat tidur, sehingga seakan-akan kulit “tertinggal” dari
area tubuh lainnya.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
Faktor teragannya
kulit akibat daya luncur antara tubuh dengan alas tempatnya berbaring akan
menyebabkan terjadinya iskemia jaringan setempat.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
Keadaan ini
terjadi bila penderita immobil, tidak dibaringkan terlentang mendatar, tetapi
pada posisi setengah duduk. Ada kecenderungan dari tubuh untuk meluncur
kebawah, apalagi keadaannya basah. Sering kali hal ini dicegah dengan
memberikan penhalang, misalnya bantal kecil/balok kayu pada kedua telapak kaki.
Upaya ini hanya akian mencegah pergerakan dari kulit, yang sekarang terfiksasi
dari alas, tetapi rangka tulang tetap cederung maju kedepan. Akibatnya terjadi
garis-garis penekanan/peregangan pada jaringan subkutan yang sekan-akan
tergunting pada tempat-tempat tertentu, dan akan terjadi penutupan arteriole
dan arteri-arteri kecil akibat terlalu teregang bahkan sampai robek. Tenaga menggunting
ini disebut <i style="mso-bidi-font-style: normal;">Shering Forces</i>.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
Sebagai tambahan
dari shering forces ini, pergerakan dari tubuh diatas alas tempatnya berbaring,
dengan fiksasi kulit pada permukaan alas akan menyebabkan terjadinya
lipatan-lipatan kulit (skin folding). Terutama terjadi pada penderita yang
kurus dengan kulit yang kendur. Lipatan-lipatan kulit yang terjadi ini dapat
menarik/mengacaukan (distorsi) dan menutup pembuluh-pembuluh darah.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
Sebagai tambahan
dari efek iskemia langsung dari faktor-faktor diatas, masih harus diperhatikan
terjadinya kerusakan edotil, penumpukan trombosit dan edema. Semua inidapat
menyebabkan nekrosis jarigan akibat lebih terganggunya aliran darah kapiler.
Kerusakan endotil juga menyebabkn pembuluh darah mudah rusak bila terkena
trauma.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
Faktor tubuh sendiri
(faktor intrinsik) juga berperan untuk terjadinya dekubitus antara lain; </div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
FAKTOR INTRINSIK</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 18pt; text-align: justify; text-indent: -18pt;">
<span style="mso-list: Ignore;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Selama penuaan, regenerasi sel pada kulit menjadi
lebih<span style="mso-spacerun: yes;"> </span>lambat sehingga kulit akan tipis
(tortora & anagnostakos, 1990)</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 18pt; text-align: justify; text-indent: -18pt;">
<span style="mso-list: Ignore;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Kandungan kolagen pada kulit yang berubah menyebabkan
elastisitas kulit berkurang sehingga rentan mengalami deformasi dan kerusakan.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 18pt; text-align: justify; text-indent: -18pt;">
<span style="mso-list: Ignore;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Kemampuan sistem kardiovaskuler yang menurun dan
sistem<span style="mso-spacerun: yes;"> </span>arteriovenosus yang kurang
kompeten menyebabkan penurunan perfusi kulit secara progresif.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 18pt; text-align: justify; text-indent: -18pt;">
<span style="mso-list: Ignore;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Sejumlah penyakit yang menimbulkan seperti DM yang
menunjukkan insufisiensi kardiovaskuler perifer dan penurunan fungsi
kardiovaskuler seperti pada sistem pernapasan menyebabkan tingkat oksigenisasi
darah pada kulit menurun.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 18pt; text-align: justify; text-indent: -18pt;">
<span style="mso-list: Ignore;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Status gizi, underweight atau kebalikannya overweight</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 18pt; text-align: justify; text-indent: -18pt;">
<span style="mso-list: Ignore;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Anemia</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 18pt; text-align: justify; text-indent: -18pt;">
<span style="mso-list: Ignore;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Hipoalbuminemia yang mempermudah terjadinya dekubitus dan
memperjelek penyembuhan dekubitus, sebaliknya bila ada dekubitus akam
menyebabkan kadar albumin darah menurun</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 18pt; text-align: justify; text-indent: -18pt;">
<span style="mso-list: Ignore;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Penyakit-penyakit neurologik, penyakit-penyakit yang
merusak pembuluh darah, juga mempermudah dan meperjelek dekubitus</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 18pt; text-align: justify; text-indent: -18pt;">
<span style="mso-list: Ignore;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Keadaan hidrasi/cairan tubuh perlu dinilai dengan cermat.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
FAKTOR EKSTRINSIK</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 18pt; text-align: justify; text-indent: -18pt;">
<span style="mso-list: Ignore;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Kebersihan tempat tidur, </div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 18pt; text-align: justify; text-indent: -18pt;">
<span style="mso-list: Ignore;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>alat-alat tenun yang kusut dan kotor, atau peralatan
medik yang menyebabkan penderita terfiksasi pada suatu sikap tertentu juga
memudahkan terjadinya dekubitus.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 18pt; text-align: justify; text-indent: -18pt;">
<span style="mso-list: Ignore;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Duduk yang buruk </div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 18pt; text-align: justify; text-indent: -18pt;">
<span style="mso-list: Ignore;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Posisi yang tidak tepat</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 18pt; text-align: justify; text-indent: -18pt;">
<span style="mso-list: Ignore;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Perubahan posisi yang kurang</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
PENAMPILAN KLINIS
DARI DEKUBITUS</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
Karakteristik
penampilan klinis dari dekubitus dapat dibagi sebagai berikut;</div>
<table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; font-family: "Courier New",Courier,monospace; margin-left: -0.25pt;">
<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0; page-break-inside: avoid;">
<td style="border-right: none; border: solid black 1.0pt; mso-border-bottom-alt: solid black .25pt; mso-border-left-alt: solid black .25pt; mso-border-top-alt: solid black .25pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 113.7pt;" valign="top" width="152">
<div class="MsoNormal" style="margin-top: 6.0pt; text-align: justify;">
Derajat I</div>
</td>
<td style="border: solid black 1.0pt; mso-border-alt: solid black .25pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 308.7pt;" valign="top" width="412">
<div class="MsoNormal" style="margin-top: 6.0pt; text-align: justify;">
Reaksi
peradangan masih terbatas pada epidermis, tampak sebagai daerah
kemerahan/eritema indurasi atau lecet.</div>
</td>
</tr>
<tr style="mso-yfti-irow: 1; page-break-inside: avoid;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; mso-border-bottom-alt: solid black .25pt; mso-border-left-alt: solid black .25pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 113.7pt;" valign="top" width="152">
<div class="MsoNormal" style="margin-top: 6.0pt; text-align: justify;">
Derajat II</div>
</td>
<td style="border-top: none; border: solid black 1.0pt; mso-border-bottom-alt: solid black .25pt; mso-border-left-alt: solid black .25pt; mso-border-right-alt: solid black .25pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 308.7pt;" valign="top" width="412">
<div class="MsoNormal" style="margin-top: 6.0pt; text-align: justify;">
<a href="http://www.blogger.com/blogger.g?blogID=2228299828902052163" name="OLE_LINK2"></a><a href="http://www.blogger.com/blogger.g?blogID=2228299828902052163" name="OLE_LINK1"><span style="mso-bookmark: OLE_LINK2;">Reaksi yang
lebih dalam lagi sampai mencapai seluruh dermis hingga lapisan lemah
subkutan, tampak sebagai ulkus yang dangkal, degan tepi yang jelas dan
perubahan warna pigmen kulit.</span></a></div>
</td>
</tr>
<tr style="mso-yfti-irow: 2; page-break-inside: avoid;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; mso-border-bottom-alt: solid black .25pt; mso-border-left-alt: solid black .25pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 113.7pt;" valign="top" width="152">
<div class="MsoNormal" style="margin-top: 6.0pt; text-align: justify;">
Derajat III</div>
</td>
<td style="border-top: none; border: solid black 1.0pt; mso-border-bottom-alt: solid black .25pt; mso-border-left-alt: solid black .25pt; mso-border-right-alt: solid black .25pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 308.7pt;" valign="top" width="412">
<div class="MsoNormal" style="margin-top: 6.0pt; text-align: justify;">
Ulkus menjadi
lebih dalam, meliputi jaringan lemak subkutan dan menggaung, berbatasan
dengan fascia dari otot-otot. Sudah mulai didapat infeksi dengan jaringan
nekrotik yang berbau.</div>
</td>
</tr>
<tr style="mso-yfti-irow: 3; mso-yfti-lastrow: yes; page-break-inside: avoid;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; mso-border-bottom-alt: solid black .25pt; mso-border-left-alt: solid black .25pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 113.7pt;" valign="top" width="152">
<div class="MsoNormal" style="margin-top: 6.0pt; text-align: justify;">
Derajat IV</div>
</td>
<td style="border-top: none; border: solid black 1.0pt; mso-border-bottom-alt: solid black .25pt; mso-border-left-alt: solid black .25pt; mso-border-right-alt: solid black .25pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 308.7pt;" valign="top" width="412">
<div class="MsoNormal" style="margin-top: 6.0pt; text-align: justify;">
Perluasan ulkus
menembus otot, hingga tampak tulang di dasar ulkus yang dapat mengakibatkan
infeksi pada tulang atau sendi.</div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
Mengingat
patofisiologi terjadinya dekubitus adalah penekanan pada daerah-daerah tonjolan
tulang, harusla diingat bahwa kerusakan jaringan dibawah tempat yang mengalami
dekubitus adalah lelih luas dari ulkusnya.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
PENGELOLAAN
DEKUBITUS</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
Pengelolaan
dekubitus diawali dengan kewaspadaan untuk mencegah terjadinya dekubitus dengan
mengenal penderita risiko tinggi terjadinya dekubitus, misalnya pada penderita
yang immobil dan konfusio.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
Usaha untuk
meremalkan terjadinya dekubitus ini antara lain dengan memakai sistem skor
Norton. Skor dibawah 14 menunjukkan adanya risiko tinggi untuk terjadinya
dekubitus. Dengan evaluasi skor ini dapat dilihat perkembangan penderita </div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
Tindakan
berikutnya adalan menjaga kebersihan penderita khususnya kulit, dengan
memandikan setiap hari. Sesudah keringkan dengan baik lalu digosok dengan
lotion, terutama dibagian kulit yang ada pada tonjolan-tonjolan tulang.
Sebaiknya diberikan massase untuk melancarkan sirkulasi darah, semua
ekskreta/sekreta harus dibersihkan dengan hati-hati agari tidak
menyebabkan<span style="mso-spacerun: yes;"> </span>lecet pada kulit penderita.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
Tindakan
selanjutnya yang berguna baik untuk pencegahan maupun setelah terjadinya
dekubitus adalah:</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 17pt; text-align: justify; text-indent: -17pt;">
<span style="mso-list: Ignore;">1.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Meningkatkan status kesehatan penderita;</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 17pt; text-align: justify;">
umum; memperbaiki
dan menjaga keadaan umum penderita, misalnya anemia diatasi, hipoalbuminemia
dikoreksi, nutirisi dan hidarasi yang cukup, vitamin (vitamin C) dan mineral
(Zn) ditambahkan.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 17pt; text-align: justify;">
khusus; coba
mengatasi/mengoabati penyakit-penyakit yang ada pada penderita, misalnya DM.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 17pt; text-align: justify; text-indent: -17pt;">
<span style="mso-list: Ignore;">2.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Mengurangi/memeratakan faktor tekanan yang mengganggu
aliran darah;</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 36.85pt; text-align: justify; text-indent: -19.85pt;">
<span style="mso-list: Ignore;">a.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Alih posisi/alih baring/tidur selang seling, paling lama
tiap dua jam. Keberatan pada cara ini adalah ketergantungan pada tenaga perawat
yang kadang-kadang sudah sangat kurang, dan kadang-kadang mengganggu istirahat
penderita<span style="mso-spacerun: yes;"> </span>bahkan menyakitkan.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 36.85pt; text-align: justify; text-indent: -19.85pt;">
<span style="mso-list: Ignore;">b.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Kasur khusus untuk lebih memambagi rata tekan yang
terjadi pada tubuh penderita, misalnya; kasur dengan gelembung tekan udara yang
naik turun, kasur air yang temperatur airnya dapat diatur. (keberatan alat
canggih ini adalah harganya mahal, perawatannya sendir harus baik dan dapat
ruasak)</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 36.85pt; text-align: justify; text-indent: -19.85pt;">
<span style="mso-list: Ignore;">c.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Regangan kulit dan lipatan kulit yang menyebabkan
sirkulasi darah setempat terganggu, dapat dikurangi antara lain;</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 54pt; text-align: justify; text-indent: -18pt;">
<span style="mso-list: Ignore;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Menjaga posisi penderita, apakah ditidurkan rata pada
tempat tidurnya, atau sudah memungkinakan untuk duduk dikursi.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 54pt; text-align: justify; text-indent: -18pt;">
<span style="mso-list: Ignore;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Bantuan balok penyangga<span style="mso-spacerun: yes;">
</span>kedua kaki, bantal-bantal kecil utuk menahan tubuh penderita, “kue
donat” untuk tumit, </div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 54pt; text-align: justify; text-indent: -18pt;">
<span style="mso-list: Ignore;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Diluar negeri sering digunakan kulit domba dengan bulu
yang lembut dan tebal sebagai alas tubuh penderita.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 36pt; text-align: justify;">
Bagitu tampak
kulit yang hiperemis pada tubuh penderita, khsusnya pada tempat-tempat yang
sering terjadi dekubitus, semua usaha-usahan diatas dilakukan dengan lebih
cermat untuk memperbaiki iskemia yang terjadi, sebab sekali terjadi kerusakan
jaringa upaya penyembuhan akan lebih rumit.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
Bila sudah
terjadi dekubitus, tentukan stadium dan tindakan medik menyesuaikan apa yang
dihadapi:</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 17pt; text-align: justify; text-indent: -17pt;">
<span style="mso-list: Ignore;">1.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Dekubitus derajat I</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 17pt; text-align: justify;">
Dengan reaksi
peradangan masih terbatas pada epidermis; </div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 17pt; text-align: justify;">
kulit yang
kemerahan dibersihkan hati-hati dengan air hangat dan sabun, diberi lotion, </div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 17pt; text-align: justify;">
kemudian
dimassase 2-3 kali/hari.</div>
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<span style="mso-list: Ignore;">2.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Dekubitus derajat II</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 17pt; text-align: justify;">
Dimana sudah
terjadi ulkus yang dangkal; </div>
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Perawatan luka harus
memperhatikan syarat-syarat aseptik dan antiseptik. </div>
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Daerah
bersangkutan digesek dengan es dan dihembus dengan udara<span style="mso-spacerun: yes;"> </span>hangat bergantian untuk meransang sirkulasi. </div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 17pt; text-align: justify;">
Dapat diberikan
salep topikal, mungkin juga untuk meransang tumbuhnya jaringan muda/granulasi, </div>
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Penggantian balut
dan salep ini jangan terlalu sering<span style="mso-spacerun: yes;">
</span>karena malahan dapat merusakkan pertumbuhan jaringan yang diharapkan.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 17pt; text-align: justify; text-indent: -17pt;">
<span style="mso-list: Ignore;">3.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Dekubitus derajat III</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 17pt; text-align: justify;">
Dengan ulkus yang
sudah dalam, menggaung sampai pada bungkus otot dan sering sudah ada infeksi; </div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 17pt; text-align: justify;">
Usahakan luka
selalu bersih dan eksudat disusahakan dapat mengalir keluar. </div>
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Balut jangan
terlalu tebal dan sebaliknya transparan sehingga permeabel untuk masukknya
udara/oksigen dan penguapan. </div>
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Kelembaban luka
dijaga tetap basah, karena akan mempermudah regenarasi sel-sel kulit. </div>
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Jika luka kotor
dapat dicuci dengan larutan NaCl fisiologis. </div>
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Antibiotik
sistemik mungkin diperlukan.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 17pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 17pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 17pt; text-align: justify; text-indent: -17pt;">
<span style="mso-list: Ignore;">4.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Dekubitus derajat IV</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 17pt; text-align: justify;">
Dengan perluasan
ulkus sampai pada dasar tulang dan sering pula diserta jaringan nekrotik;</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 17pt; text-align: justify;">
Semua
langkah-langkah diatas tetap dikerjakan dan jaringan nekrotik yang adal harus
dibersihkan , sebaba akan menghalangi pertumbuhgan jaringan/epitelisasi.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 17pt; text-align: justify;">
Beberapa preparat
enzim coba diberikan untuk usaha ini, dengan tujuan mengurangi perdarahan,
dibanding tindakan bedah yang juga merupakan alternatif lain. Setelah jaringan
nekrotik dibuang danluka bersih, penyembuhan luka<span style="mso-spacerun: yes;"> </span>secara alami dapat diharapkan.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 17pt; text-align: justify;">
Beberapa usaha
mempercepat adalah antara lain dengan memberikan oksigenisasi pada daerah luka,
</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 17pt; text-align: justify;">
Tindakan dengan
ultrasono untuk membuka sumbatan-sumbatan pembuluh darah dan sampai pada
transplantasi kulit setempat.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 0.0001pt 17pt; text-align: justify;">
Angka mortalitas
dekubitus derajat IV ini dapat mencapai 40%.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin-top: 6pt; text-align: justify;">
SKOR NORTON UNTUK
MENGUKUR RISIKO DEKUBITUS.</div>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; margin: 6pt 0cm 12.8pt;">
<a href="http://www.blogger.com/blogger.g?blogID=2228299828902052163" name="_1207104633"></a><a href="http://www.blogger.com/blogger.g?blogID=2228299828902052163" name="_1207105377"></a><a href="http://www.blogger.com/blogger.g?blogID=2228299828902052163" name="_1207106064"></a><a href="http://www.blogger.com/blogger.g?blogID=2228299828902052163" name="_1207106145"></a><a href="http://www.blogger.com/blogger.g?blogID=2228299828902052163" name="_1207106161"></a><a href="http://www.blogger.com/blogger.g?blogID=2228299828902052163" name="_1207106226"></a><a href="http://www.blogger.com/blogger.g?blogID=2228299828902052163" name="_1207106240"></a><a href="http://www.blogger.com/blogger.g?blogID=2228299828902052163" name="_1207106433"></a><span lang="EN-US"><img height="415" src="file:///C:%5CUsers%5CAcer%5CAppData%5CLocal%5CTemp%5Cmsohtmlclip1%5C01%5Cclip_image002.gif" width="537" /></span>Risiko dekubitus jika skor total ≤ 14<span lang="EN-US"></span></div>
ERFANSYAH. HRhttp://www.blogger.com/profile/07497970584312798191noreply@blogger.com0tag:blogger.com,1999:blog-2228299828902052163.post-27698911302000324202012-11-21T05:51:00.001-08:002013-03-11T10:03:24.312-07:00Asuhan Keperawatan Diabetes Mellitus Aplikasi NANDA, NIC, NOC<h3 class="post-title entry-title" itemprop="name">
Asuhan Keperawatan Diabetes Mellitus Aplikasi NANDA, NIC, NOC
</h3>
<br />
<div class="Section1">
<br />
<div class="MsoHeading7">
A. Masalah Yang lazim muncul pada klien</div>
<div class="MsoNormal" style="line-height: 150%; margin-left: .5in; mso-list: l6 level1 lfo15; tab-stops: list .5in 81.0pt; text-indent: -.25in;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">1.<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Defisit Volume Cairan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: .5in; mso-list: l6 level1 lfo15; tab-stops: list .5in 81.0pt; text-indent: -.25in;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">2.<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Pola Nafas tidak efektif</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">3.<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Resiko Infeksi</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: .5in; mso-list: l6 level1 lfo15; tab-stops: list .5in 81.0pt; text-indent: -.25in;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">4.<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Ketidakseimbangan nutrisi kurang dari kebutuhan tubuh</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: .5in; mso-list: l6 level1 lfo15; tab-stops: list .5in 81.0pt; text-indent: -.25in;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">5.<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Cemas</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: .5in; mso-list: l6 level1 lfo15; tab-stops: list .5in 81.0pt; text-indent: -.25in;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">6.<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Kurang pengetahuan</span></div>
<div class="MsoNormal">
</div>
<h5 style="margin-left: 9.0pt; mso-list: none; tab-stops: .5in; text-indent: 0in;">
<span style="font-size: 11pt; font-style: normal; line-height: 150%;">B. </span><span style="font-style: normal;">Discharge Planning</span><span style="font-size: 11pt; font-style: normal; line-height: 150%;"></span></h5>
<div class="MsoNormal" style="line-height: 150%; margin-left: 45.0pt; mso-list: l1 level1 lfo16; tab-stops: 27.0pt list 45.0pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">1.<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Berikan penjelasan secara lisan dan tulisan tentang
perawatan dan pengobatan yang diberikan.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 45.0pt; mso-list: l1 level1 lfo16; tab-stops: 27.0pt list 45.0pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">2.<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Ajarkan dan evaluasi untuk mengenal gejala syok dan
asidosis diabetik dan penanganan kedaruratan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 45.0pt; mso-list: l1 level1 lfo16; tab-stops: 27.0pt list 45.0pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">3.<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Simulasikan cara pemberian terapi insulin mulai dari
persiapan alat sampai penyuntikan dan lokai</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 45.0pt; mso-list: l1 level1 lfo16; tab-stops: 27.0pt list 45.0pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">4.<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Ajarkan memonitor atau memeriksa glukosa darah dan
glukosa dalam urine</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 45.0pt; mso-list: l1 level1 lfo16; tab-stops: 27.0pt list 45.0pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">5.<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Perencanaan diit, buat jadwal</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 45.0pt; mso-list: l1 level1 lfo16; tab-stops: 27.0pt list 45.0pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">6.<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Perencanaan latihan, jelaskan dampak latihan dengan
diabetik</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 45.0pt; mso-list: l1 level1 lfo16; tab-stops: 27.0pt list 45.0pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">7.<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Ajarkan gabaimana untukmencegah hiperglikemi dan
hipoglikemi daninfomasikan gejala gejala yang muncul darikeduanya.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 45.0pt; mso-list: l1 level1 lfo16; tab-stops: 27.0pt list 45.0pt; text-align: justify; text-indent: -.25in;">
8.<span style="font: 7pt "Times New Roman";">
</span><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Jelaskan komplikasi yang
muncul</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 45.0pt; mso-list: l1 level1 lfo16; tab-stops: 27.0pt list 45.0pt; text-align: justify; text-indent: -.25in;">
9.<span style="font: 7pt "Times New Roman";">
</span><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Ajarkan mencegah infeksi :
keberihan kaki, hindari perlukaan,gunakan sikat gigi yang halus.</span></div>
<div class="MsoNormal" style="line-height: 150%; tab-stops: 27.0pt; text-align: justify;">
</div>
<div class="MsoNormal" style="line-height: 150%; tab-stops: 27.0pt; text-align: justify;">
</div>
</div>
<span style="font-family: "Times New Roman","serif"; font-size: 12pt; line-height: 150%;"><br clear="all" style="mso-break-type: section-break; page-break-before: always;" />
</span>
<br />
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: none; mso-border-alt: solid black .75pt; mso-border-insideh: .75pt solid black; mso-border-insidev: .75pt solid black; mso-padding-alt: 0in 5.4pt 0in 5.4pt; mso-yfti-tbllook: 191; width: 100.02%;"><tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td style="background: #CCCCCC; border: solid black 1.0pt; mso-border-alt: solid black .75pt; padding: 0in 5.4pt 0in 5.4pt; width: 4.38%;" valign="top" width="4%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt;">No</span></div>
</td>
<td style="background: #CCCCCC; border-left: none; border: solid black 1.0pt; mso-border-alt: solid black .75pt; mso-border-left-alt: solid black .75pt; padding: 0in 5.4pt 0in 5.4pt; width: 30.54%;" valign="top" width="30%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt;">Diagnosa
Keperawatan</span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
</div>
</td>
<td style="background: #CCCCCC; border-left: none; border: solid black 1.0pt; mso-border-alt: solid black .75pt; mso-border-left-alt: solid black .75pt; padding: 0in 5.4pt 0in 5.4pt; width: 29.1%;" valign="top" width="29%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt;">Itujuan
Dan Kriteria Hasil</span></div>
</td>
<td style="background: #CCCCCC; border-left: none; border: solid black 1.0pt; mso-border-alt: solid black .75pt; mso-border-left-alt: solid black .75pt; padding: 0in 5.4pt 0in 5.4pt; width: 35.98%;" valign="top" width="35%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt;">Intervensi</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 1;">
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .75pt; mso-border-top-alt: solid black .75pt; padding: 0in 5.4pt 0in 5.4pt; width: 4.38%;" valign="top" width="4%"><div align="center" class="MsoNormal" style="text-align: center;">
1</div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .75pt; mso-border-left-alt: solid black .75pt; mso-border-top-alt: solid black .75pt; padding: 0in 5.4pt 0in 5.4pt; width: 30.54%;" valign="top" width="30%"><div class="MsoNormal" style="line-height: 150%;">
<span lang="IT" style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Defisit Volume Cairan</span></div>
<div class="MsoNormal">
<span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Definisi : Penurunan cairan intravaskuler,
interstisial, dan/atau intrasellular. Ini mengarah ke dehidrasi, kehilangan
cairan dengan pengeluaran sodium</span></div>
<div class="MsoNormal">
</div>
<div class="MsoNormal">
<span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Batasan Karakteristik : </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Kelemahan </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Haus </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Penurunan turgor kulit/lidah </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Membran mukosa/kulit kering </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Peningkatan denyut nadi, penurunan tekanan
darah, penurunan volume/tekanan nadi </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Pengisian vena menurun </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Perubahan status mental</span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Konsentrasi urine meningkat </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Temperatur tubuh meningkat </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Hematokrit meninggi </span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;"></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Kehilangan berat badan seketika (kecuali pada third spacing)</span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;"></span></div>
<div class="MsoNormal">
<span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Faktor-faktor yang berhubungan: </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Kehilangan volume cairan secara aktif </span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;"></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Kegagalan mekanisme pengaturan</span><span style="font-family: "Arial","sans-serif"; font-size: 11pt;"></span></div>
<div class="MsoNormal">
</div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .75pt; mso-border-left-alt: solid black .75pt; mso-border-top-alt: solid black .75pt; padding: 0in 5.4pt 0in 5.4pt; width: 29.1%;" valign="top" width="29%"><div class="MsoNormal" style="text-align: justify;">
<b><span style="font-family: "Arial","sans-serif";">NOC: </span></b></div>
<div class="MsoNormal" style="margin-left: 24.4pt; mso-list: l0 level1 lfo8; tab-stops: list 24.4pt 81.0pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif";">Fluid
balance</span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; mso-list: l0 level1 lfo8; tab-stops: list 24.4pt 81.0pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif";">Hydration</span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; mso-list: l0 level1 lfo8; tab-stops: list 24.4pt 81.0pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif";">Nutritional
Status : Food and Fluid Intake</span></div>
<div class="MsoNormal" style="text-align: justify;">
<b><span style="font-family: "Arial","sans-serif";">Kriteria Hasil :</span></b></div>
<div class="MsoNormal" style="margin-left: 24.4pt; mso-list: l15 level1 lfo9; tab-stops: list 24.4pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif";">Mempertahankan
urine output sesuai dengan usia dan BB, BJ urine normal, HT normal</span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; mso-list: l15 level1 lfo9; tab-stops: list 24.4pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif";">Tekanan
darah, nadi, suhu tubuh dalam batas normal</span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; mso-list: l15 level1 lfo9; tab-stops: list 24.4pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif";">Tidak
ada tanda tanda dehidrasi, Elastisitas turgor kulit baik, membran mukosa
lembab, tidak ada rasa haus yang berlebihan</span></div>
<div class="MsoNormal" style="text-align: justify;">
</div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .75pt; mso-border-left-alt: solid black .75pt; mso-border-top-alt: solid black .75pt; padding: 0in 5.4pt 0in 5.4pt; width: 35.98%;" valign="top" width="35%"><div class="MsoBodyTextIndent" style="line-height: normal; margin-left: 0in;">
<b><span style="font-family: "Arial","sans-serif";">NIC :</span></b></div>
<div class="MsoHeading9">
Fluid management</div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l12 level1 lfo21; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Timbang popok/pembalut jika diperlukan </span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l12 level1 lfo21; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Pertahankan catatan intake dan output yang akurat</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l12 level1 lfo21; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor status hidrasi ( kelembaban membran mukosa,
nadi adekuat, tekanan darah ortostatik ), jika diperlukan</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l12 level1 lfo21; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor vital sign</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l12 level1 lfo21; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor masukan makanan / cairan dan hitung intake
kalori harian</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l12 level1 lfo21; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Kolaborasikan pemberian cairan IV </span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l12 level1 lfo21; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor status nutrisi</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l12 level1 lfo21; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Berikan cairan IV pada suhu ruangan </span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l12 level1 lfo21; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Dorong masukan oral</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l12 level1 lfo21; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Berikan penggantian nesogatrik sesuai output</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l12 level1 lfo21; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Dorong keluarga untuk membantu pasien makan</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l12 level1 lfo21; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Tawarkan snack ( jus
buah, buah segar )</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l12 level1 lfo21; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="IT" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="IT" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Kolaborasi dokter jika tanda cairan berlebih muncul
meburuk </span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l12 level1 lfo21; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Atur kemungkinan tranfusi</span><b><span style="font-family: "Arial Narrow","sans-serif";"></span></b></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l12 level1 lfo21; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Persiapan untuk tranfusi</span><b><span style="font-family: "Comic Sans MS";"></span></b></div>
<div class="MsoNormal">
</div>
</td>
</tr>
<tr style="mso-yfti-irow: 2;">
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .75pt; mso-border-top-alt: solid black .75pt; padding: 0in 5.4pt 0in 5.4pt; width: 4.38%;" valign="top" width="4%"><div align="center" class="MsoNormal" style="text-align: center;">
2</div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .75pt; mso-border-left-alt: solid black .75pt; mso-border-top-alt: solid black .75pt; padding: 0in 5.4pt 0in 5.4pt; width: 30.54%;" valign="top" width="30%"><div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt;">Pola Nafas tidak efektif</span></div>
<div class="MsoNormal">
</div>
<div class="MsoNormal">
<span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Definisi : Pertukaran udara inspirasi dan/atau ekspirasi tidak
adekuat</span></div>
<div class="MsoNormal">
</div>
<div class="MsoNormal">
<span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Batasan karakteristik : </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Penurunan tekanan inspirasi/ekspirasi </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Penurunan pertukaran udara per menit </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Menggunakan otot pernafasan tambahan </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Nasal flaring </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Dyspnea</span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Orthopnea </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Perubahan penyimpangan dada </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Nafas pendek </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Assumption of 3-point position </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Pernafasan pursed-lip </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Tahap ekspirasi berlangsung sangat lama </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Peningkatan diameter anterior-posterior </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Pernafasan rata-rata/minimal </span></div>
<div class="MsoNormal" style="margin-left: 31.85pt; mso-list: l13 level3 lfo26; text-indent: -.25in;">
<span lang="NO-BOK" style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Bayi : < 25 atau >
60</span></div>
<div class="MsoNormal" style="margin-left: 31.85pt; mso-list: l13 level3 lfo26; text-indent: -.25in;">
<span lang="NO-BOK" style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Usia 1-4 : < 20 atau
> 30</span></div>
<div class="MsoNormal" style="margin-left: 31.85pt; mso-list: l13 level3 lfo26; text-indent: -.25in;">
<span lang="NO-BOK" style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Usia 5-14 : < 14 atau
> 25</span></div>
<div class="MsoNormal" style="margin-left: 31.85pt; mso-list: l13 level3 lfo26; text-indent: -.25in;">
<span lang="NO-BOK" style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Usia > 14 : < 11
atau > 24</span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Kedalaman pernafasan </span></div>
<div class="MsoNormal" style="margin-left: 31.85pt; mso-list: l13 level3 lfo26; text-indent: -.25in;">
<span lang="NO-BOK" style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Dewasa volume tidalnya
500 ml saat istirahat </span></div>
<div class="MsoNormal" style="margin-left: 31.85pt; mso-list: l13 level3 lfo26; text-indent: -.25in;">
<span lang="NO-BOK" style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Bayi volume tidalnya 6-8
ml/Kg</span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Timing rasio </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 10.5pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Penurunan kapasitas vital</span><span lang="NO-BOK" style="font-family: "Arial","sans-serif"; font-size: 10.5pt;"></span></div>
<div class="MsoNormal">
</div>
<div class="MsoNormal">
<span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Faktor yang berhubungan : </span></div>
<div class="MsoNormal" style="margin-left: .5in; mso-list: l13 level1 lfo26; tab-stops: list .5in; text-indent: -.25in;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Hiperventilasi </span></div>
<div class="MsoNormal" style="margin-left: .5in; mso-list: l13 level1 lfo26; tab-stops: list .5in; text-indent: -.25in;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Deformitas tulang </span></div>
<div class="MsoNormal" style="margin-left: .5in; mso-list: l13 level1 lfo26; tab-stops: list .5in; text-indent: -.25in;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Kelainan bentuk dinding dada </span></div>
<div class="MsoNormal" style="margin-left: .5in; mso-list: l13 level1 lfo26; tab-stops: list .5in; text-indent: -.25in;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Penurunan energi/kelelahan </span></div>
<div class="MsoNormal" style="margin-left: .5in; mso-list: l13 level1 lfo26; tab-stops: list .5in; text-indent: -.25in;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Perusakan/pelemahan muskulo-skeletal </span></div>
<div class="MsoNormal" style="margin-left: .5in; mso-list: l13 level1 lfo26; tab-stops: list .5in; text-indent: -.25in;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Obesitas </span></div>
<div class="MsoNormal" style="margin-left: .5in; mso-list: l13 level1 lfo26; tab-stops: list .5in; text-indent: -.25in;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Posisi tubuh </span></div>
<div class="MsoNormal" style="margin-left: .5in; mso-list: l13 level1 lfo26; tab-stops: list .5in; text-indent: -.25in;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Kelelahan otot pernafasan </span></div>
<div class="MsoNormal" style="margin-left: .5in; mso-list: l13 level1 lfo26; tab-stops: list .5in; text-indent: -.25in;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Hipoventilasi sindrom </span></div>
<div class="MsoNormal" style="margin-left: .5in; mso-list: l13 level1 lfo26; tab-stops: list .5in; text-indent: -.25in;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Nyeri </span></div>
<div class="MsoNormal" style="margin-left: .5in; mso-list: l13 level1 lfo26; tab-stops: list .5in; text-indent: -.25in;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Kecemasan </span></div>
<div class="MsoNormal" style="margin-left: .5in; mso-list: l13 level1 lfo26; tab-stops: list .5in; text-indent: -.25in;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Disfungsi Neuromuskuler </span></div>
<div class="MsoNormal" style="margin-left: .5in; mso-list: l13 level1 lfo26; tab-stops: list .5in; text-indent: -.25in;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Kerusakan persepsi/kognitif </span></div>
<div class="MsoNormal" style="margin-left: .5in; mso-list: l13 level1 lfo26; text-indent: -.25in;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Perlukaan pada jaringan syaraf tulang belakang </span></div>
<div class="MsoNormal" style="margin-left: .5in; mso-list: l13 level1 lfo26; text-indent: -.25in;">
<span lang="NO-BOK" style="font-size: 10.5pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Imaturitas Neurologis</span><span lang="NO-BOK" style="font-family: "Arial","sans-serif"; font-size: 10.5pt;"></span></div>
<div class="MsoNormal">
</div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .75pt; mso-border-left-alt: solid black .75pt; mso-border-top-alt: solid black .75pt; padding: 0in 5.4pt 0in 5.4pt; width: 29.1%;" valign="top" width="29%"><div class="MsoNormal" style="text-align: justify;">
<b><span style="font-family: "Arial","sans-serif";">NOC : </span></b></div>
<div class="MsoNormal" style="margin-left: .3in; mso-list: l25 level1 lfo1; tab-stops: list .5in 81.0pt; text-indent: -.25in;">
<span style="font-family: Wingdings; font-size: 11pt;">v<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Respiratory
status : Ventilation</span></div>
<div class="MsoNormal" style="margin-left: .3in; mso-list: l8 level1 lfo3; tab-stops: list .3in; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings; font-size: 11pt;">v<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Respiratory
status : Airway patency</span></div>
<div class="MsoNormal" style="margin-left: .3in; mso-list: l8 level1 lfo3; tab-stops: list .3in; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings; font-size: 11pt;">v<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Vital
sign Status</span></div>
<div class="MsoNormal" style="text-align: justify;">
<b><span style="font-family: "Arial","sans-serif";">Kriteria Hasil :</span></b></div>
<div class="MsoNormal" style="margin-left: 21.5pt; mso-list: l26 level1 lfo2; tab-stops: list 45.0pt 81.0pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings; font-size: 11pt;">v<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Mendemonstrasikan batuk efektif dan suara nafas
yang bersih, tidak ada sianosis dan dyspneu (mampu mengeluarkan sputum, mampu
bernafas dengan mudah, tidak ada pursed lips)</span></div>
<div class="MsoNormal" style="margin-left: 21.5pt; mso-list: l26 level1 lfo2; tab-stops: list 39.55pt 45.0pt 81.0pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Menunjukkan
jalan nafas yang paten</span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;"> (</span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">klien tidak merasa tercekik, irama nafas,
frekuensi pernafasan dalam rentang normal, tidak ada suara nafas abnormal)</span></div>
<div class="MsoNormal" style="margin-left: 21.5pt; mso-list: l26 level1 lfo2; tab-stops: list 39.55pt 45.0pt 81.0pt; text-align: justify; text-indent: -.25in;">
<span lang="IT" style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";"> </span></span><span lang="IT" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Tanda Tanda vital dalam
rentang normal (tekanan darah, nadi, pernafasan)</span><span lang="IT"></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .75pt; mso-border-left-alt: solid black .75pt; mso-border-top-alt: solid black .75pt; padding: 0in 5.4pt 0in 5.4pt; width: 35.98%;" valign="top" width="35%"><div class="MsoNormal" style="text-align: justify;">
<b><span style="font-family: "Arial","sans-serif";">NIC : </span></b></div>
<h1>
Airway Management</h1>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l16 level1 lfo17; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Buka jalan nafas, guanakan teknik chin lift atau jaw
thrust bila perlu</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l16 level1 lfo17; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Posisikan pasien untuk memaksimalkan ventilasi</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l16 level1 lfo17; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="FR" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="FR" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Identifikasi pasien perlunya pemasangan alat jalan
nafas buatan </span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l16 level1 lfo17; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="FR" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="FR" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Pasang mayo bila perlu</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l16 level1 lfo17; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="FR" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="FR" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Lakukan fisioterapi dada jika perlu</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l16 level1 lfo17; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="FR" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="FR" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Keluarkan sekret dengan batuk atau suction</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l16 level1 lfo17; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="FR" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="FR" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Auskultasi suara nafas, catat adanya suara tambahan</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l16 level1 lfo17; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="FR" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="FR" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Lakukan suction pada mayo</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l16 level1 lfo17; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="FR" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="FR" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Berikan bronkodilator bila perlu</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l16 level1 lfo17; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="FR" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="FR" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Berikan pelembab udara Kassa basah NaCl Lembab</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l16 level1 lfo17; tab-stops: list 21.55pt 81.0pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="FR" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Atur intake untuk cairan mengoptimalkan keseimbangan.</span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;"></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l16 level1 lfo17; tab-stops: list 21.55pt 81.0pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="FR" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor respirasi dan status O2</span><span style="font-family: "Arial Narrow","sans-serif";"></span></div>
<div class="MsoNormal" style="margin-left: 3.55pt; tab-stops: list 81.0pt; text-align: justify;">
</div>
<div class="MsoNormal" style="margin-left: 3.8pt; text-align: justify;">
<b><span style="font-family: "Arial Narrow","sans-serif";">Terapi oksigen</span></b></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l16 level2 lfo17; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Wingdings; font-size: 11pt;">v<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Bersihkan mulut, hidung dan secret trakea</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l16 level2 lfo17; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings; font-size: 11pt;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Pertahankan jalan nafas yang
paten</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l16 level2 lfo17; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings; font-size: 11pt;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Atur peralatan oksigenasi</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l16 level2 lfo17; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings; font-size: 11pt;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor aliran oksigen</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l16 level2 lfo17; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings; font-size: 11pt;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Pertahankan posisi pasien</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l16 level2 lfo17; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings; font-size: 11pt;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Onservasi adanya tanda tanda
hipoventilasi</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l16 level2 lfo17; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor adanya kecemasan pasien terhadap oksigenasi</span><b><span lang="NL"></span></b></div>
<div class="MsoNormal" style="margin-left: 3.8pt; text-align: justify;">
</div>
<div class="MsoNormal" style="margin-left: 3.8pt; text-align: justify;">
<b><span style="font-family: "Arial Narrow","sans-serif";">Vital sign Monitoring</span></b><span style="font-family: "Arial Narrow","sans-serif";"></span></div>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="mso-list: l21 level1 lfo18; tab-stops: list .5in; text-align: justify;"><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor TD, nadi, suhu, dan RR</span></li>
<li class="MsoNormal" style="mso-list: l21 level1 lfo18; tab-stops: list .5in; text-align: justify;"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Catat adanya fluktuasi tekanan darah</span></li>
<li class="MsoNormal" style="mso-list: l21 level1 lfo18; tab-stops: list .5in; text-align: justify;"><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor VS saat pasien berbaring, duduk, atau berdiri</span></li>
<li class="MsoNormal" style="mso-list: l21 level1 lfo18; tab-stops: list .5in; text-align: justify;"><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Auskultasi TD pada kedua lengan dan bandingkan</span></li>
<li class="MsoNormal" style="mso-list: l21 level1 lfo18; tab-stops: list .5in; text-align: justify;"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor TD, nadi, RR, sebelum, selama, dan
setelah aktivitas</span></li>
<li class="MsoNormal" style="mso-list: l21 level1 lfo18; tab-stops: list .5in; text-align: justify;"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor kualitas dari nadi</span></li>
<li class="MsoNormal" style="mso-list: l21 level1 lfo18; tab-stops: list .5in; text-align: justify;"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor frekuensi dan irama pernapasan</span></li>
<li class="MsoNormal" style="mso-list: l21 level1 lfo18; tab-stops: list .5in; text-align: justify;"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor suara paru</span></li>
<li class="MsoNormal" style="mso-list: l21 level1 lfo18; tab-stops: list .5in; text-align: justify;"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor pola pernapasan abnormal</span></li>
<li class="MsoNormal" style="mso-list: l21 level1 lfo18; tab-stops: list .5in; text-align: justify;"><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor suhu, warna, dan kelembaban kulit</span></li>
<li class="MsoNormal" style="mso-list: l21 level1 lfo18; tab-stops: list .5in; text-align: justify;"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor sianosis perifer</span></li>
<li class="MsoNormal" style="mso-list: l21 level1 lfo18; tab-stops: list .5in; text-align: justify;"><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor adanya cushing triad (tekanan nadi
yang melebar, bradikardi, peningkatan sistolik)</span><span style="font-family: "Arial Narrow","sans-serif";"></span></li>
<li class="MsoNormal" style="mso-list: l21 level1 lfo18; tab-stops: list .5in; text-align: justify;"><span lang="IT" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Identifikasi penyebab dari perubahan vital sign</span><span lang="IT" style="font-family: "Arial Narrow","sans-serif";"></span></li>
</ul>
<div class="MsoNormal">
</div>
</td>
</tr>
<tr style="mso-yfti-irow: 3;">
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .75pt; mso-border-top-alt: solid black .75pt; padding: 0in 5.4pt 0in 5.4pt; width: 4.38%;" valign="top" width="4%"><div align="center" class="MsoNormal" style="text-align: center;">
3</div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .75pt; mso-border-left-alt: solid black .75pt; mso-border-top-alt: solid black .75pt; padding: 0in 5.4pt 0in 5.4pt; width: 30.54%;" valign="top" width="30%"><div class="MsoNormal" style="line-height: 150%;">
<span lang="IT" style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Resiko Infeksi</span></div>
<div class="MsoNormal">
<span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Definisi : Peningkatan resiko masuknya organisme patogen</span></div>
<div class="MsoNormal">
</div>
<div class="MsoNormal">
<span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Faktor-faktor resiko : </span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; mso-list: l13 level1 lfo26; tab-stops: list 20.1pt; text-indent: -.25in;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Prosedur Infasif</span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; mso-list: l13 level1 lfo26; tab-stops: list 20.1pt; text-indent: -.25in;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Ketidakcukupan pengetahuan untuk menghindari
paparan patogen </span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; mso-list: l13 level1 lfo26; tab-stops: list 20.1pt; text-indent: -.25in;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Trauma </span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; mso-list: l13 level1 lfo26; tab-stops: list 20.1pt; text-indent: -.25in;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Kerusakan jaringan dan peningkatan paparan
lingkungan </span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; mso-list: l13 level1 lfo26; tab-stops: list 20.1pt; text-indent: -.25in;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Ruptur membran amnion</span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; mso-list: l13 level1 lfo26; tab-stops: list 20.1pt; text-indent: -.25in;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Agen farmasi (imunosupresan)</span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; mso-list: l13 level1 lfo26; tab-stops: list 20.1pt; text-indent: -.25in;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Malnutrisi </span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; mso-list: l13 level1 lfo26; tab-stops: list 20.1pt; text-indent: -.25in;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Peningkatan paparan lingkungan patogen </span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; mso-list: l13 level1 lfo26; tab-stops: list 20.1pt; text-indent: -.25in;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Imonusupresi </span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; mso-list: l13 level1 lfo26; tab-stops: list 20.1pt; text-indent: -.25in;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Ketidakadekuatan imum buatan </span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; mso-list: l13 level1 lfo26; tab-stops: list 20.1pt; text-indent: -.25in;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Tidak adekuat pertahanan sekunder (penurunan Hb,
Leukopenia, penekanan respon inflamasi)</span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; mso-list: l13 level1 lfo26; tab-stops: list 20.1pt; text-indent: -.25in;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Tidak adekuat pertahanan tubuh primer (kulit tidak
utuh, trauma jaringan, penurunan kerja silia, cairan tubuh statis, perubahan
sekresi pH, perubahan peristaltik)</span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; mso-list: l13 level1 lfo26; tab-stops: list 20.1pt; text-indent: -.25in;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Penyakit kronik</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .75pt; mso-border-left-alt: solid black .75pt; mso-border-top-alt: solid black .75pt; padding: 0in 5.4pt 0in 5.4pt; width: 29.1%;" valign="top" width="29%"><div class="MsoNormal" style="text-align: justify;">
<b><span style="font-family: "Arial","sans-serif";">NOC : </span></b></div>
<div class="MsoNormal" style="margin-left: 30.7pt; mso-list: l24 level1 lfo10; tab-stops: list 30.7pt 81.0pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif";">Immune
Status</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; mso-list: l24 level1 lfo10; tab-stops: list 30.7pt 81.0pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif";">Knowledge
: Infection control</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; mso-list: l24 level1 lfo10; tab-stops: list 30.7pt 81.0pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif";">Risk
control</span></div>
<div class="MsoNormal" style="text-align: justify;">
<b><span style="font-family: "Arial","sans-serif";">Kriteria Hasil :</span></b></div>
<div class="MsoNormal" style="margin-left: 30.7pt; mso-list: l23 level1 lfo11; tab-stops: list 30.7pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif";">Klien
bebas dari tanda dan gejala infeksi</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; mso-list: l23 level1 lfo11; tab-stops: list 30.7pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif";">Menunjukkan
kemampuan untuk mencegah timbulnya infeksi</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; mso-list: l23 level1 lfo11; tab-stops: list 30.7pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif";">Jumlah
leukosit dalam batas normal</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; mso-list: l23 level1 lfo11; tab-stops: list 30.7pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif";">Menunjukkan
perilaku hidup sehat</span></div>
<div class="MsoNormal">
</div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .75pt; mso-border-left-alt: solid black .75pt; mso-border-top-alt: solid black .75pt; padding: 0in 5.4pt 0in 5.4pt; width: 35.98%;" valign="top" width="35%"><div class="MsoNormal" style="text-align: justify;">
<b><span style="font-family: "Arial","sans-serif";">NIC :</span></b></div>
<div class="MsoNormal" style="text-align: justify;">
<b><span style="font-family: "Arial Narrow","sans-serif";">Infection Control (Kontrol infeksi)</span></b></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l9 level1 lfo23; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="FR" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="FR" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Bersihkan lingkungan setelah dipakai pasien lain</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l9 level1 lfo23; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="FR" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="FR" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Pertahankan teknik isolasi</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l9 level1 lfo23; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="FR" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="FR" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Batasi pengunjung bila perlu</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l9 level1 lfo23; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="FR" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="FR" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Instruksikan pada pengunjung untuk mencuci tangan saat
berkunjung dan setelah berkunjung meninggalkan pasien</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l9 level1 lfo23; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="IT" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="IT" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Gunakan sabun antimikrobia untuk cuci tangan</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l9 level1 lfo23; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="IT" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="IT" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Cuci tangan setiap sebelum dan sesudah tindakan
kperawtan</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l9 level1 lfo23; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Gunakan baju, sarung
tangan sebagai alat pelindung</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l9 level1 lfo23; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Pertahankan lingkungan aseptik selama pemasangan alat</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l9 level1 lfo23; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Ganti letak IV perifer dan line central dan dressing
sesuai dengan petunjuk umum</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l9 level1 lfo23; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Gunakan kateter intermiten untuk menurunkan infeksi
kandung kencing </span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l9 level1 lfo23; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Tingktkan intake nutrisi</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l9 level1 lfo23; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Berikan terapi antibiotik bila perlu</span><b><span style="font-family: "Arial Narrow","sans-serif";"></span></b></div>
<div class="MsoNormal" style="margin-left: 3.65pt; text-align: justify;">
</div>
<div class="MsoNormal" style="text-align: justify;">
<b><span style="font-family: "Arial Narrow","sans-serif";">Infection Protection (proteksi terhadap infeksi)</span></b><span style="font-family: "Arial Narrow","sans-serif";"></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l19 level1 lfo24; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor tanda dan gejala infeksi sistemik dan lokal</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l19 level1 lfo24; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor hitung granulosit, WBC</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l19 level1 lfo24; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor kerentanan terhadap infeksi</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l19 level1 lfo24; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Batasi pengunjung</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l19 level1 lfo24; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Saring pengunjung terhadap penyakit menular</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l19 level1 lfo24; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Partahankan teknik aspesis pada pasien yang beresiko</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l19 level1 lfo24; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Pertahankan teknik isolasi k/p</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l19 level1 lfo24; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Berikan perawatan kuliat pada area epidema</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l19 level1 lfo24; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Inspeksi kulit dan membran mukosa terhadap kemerahan,
panas, drainase</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l19 level1 lfo24; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Ispeksi kondisi luka / insisi bedah</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l19 level1 lfo24; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Dorong masukkan nutrisi yang cukup</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l19 level1 lfo24; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Dorong masukan cairan</span></div>
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<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Dorong istirahat</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l19 level1 lfo24; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Instruksikan pasien untuk minum antibiotik sesuai resep</span></div>
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<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Ajarkan pasien dan keluarga tanda dan gejala infeksi</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l19 level1 lfo24; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Ajarkan cara menghindari infeksi</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l19 level1 lfo24; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Laporkan kecurigaan infeksi</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l19 level1 lfo24; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Laporkan kultur positif</span><span style="font-family: "Comic Sans MS"; font-size: 11pt;"></span></div>
<div class="MsoNormal" style="text-align: justify;">
</div>
<div class="MsoNormal">
</div>
</td>
</tr>
<tr style="mso-yfti-irow: 4;">
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .75pt; mso-border-top-alt: solid black .75pt; padding: 0in 5.4pt 0in 5.4pt; width: 4.38%;" valign="top" width="4%"><div align="center" class="MsoNormal" style="text-align: center;">
4</div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .75pt; mso-border-left-alt: solid black .75pt; mso-border-top-alt: solid black .75pt; padding: 0in 5.4pt 0in 5.4pt; width: 30.54%;" valign="top" width="30%"><div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt;">Ketidakseimbangan nutrisi kurang dari
kebutuhan tubuh</span></div>
<div class="MsoNormal">
</div>
<div class="MsoNormal">
<span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Definisi : Intake nutrisi tidak cukup untuk
keperluan metabolisme tubuh.</span></div>
<div class="MsoNormal">
</div>
<div class="MsoNormal">
<span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Batasan karakteristik : </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Berat badan 20 % atau lebih di bawah ideal </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Dilaporkan adanya intake makanan yang kurang
dari RDA (Recomended Daily Allowance) </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Membran mukosa dan konjungtiva pucat </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Kelemahan otot yang digunakan untuk
menelan/mengunyah </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Luka, inflamasi pada rongga mulut </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Mudah merasa kenyang, sesaat setelah
mengunyah makanan </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Dilaporkan atau fakta adanya kekurangan
makanan </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Dilaporkan adanya perubahan sensasi rasa </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Perasaan ketidakmampuan untuk mengunyah
makanan </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Miskonsepsi </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Kehilangan BB dengan makanan cukup </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Keengganan untuk makan </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Kram pada abdomen </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Tonus otot jelek </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Nyeri abdominal dengan atau tanpa patologi </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Kurang berminat terhadap makanan</span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Pembuluh darah kapiler mulai rapuh </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Diare dan atau steatorrhea </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span lang="NO-BOK" style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Kehilangan rambut yang cukup banyak (rontok) </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Suara usus hiperaktif</span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;"></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; mso-list: l13 level1 lfo26; tab-stops: list 13.85pt; text-indent: -9.0pt;">
<span style="font-size: 11pt;">-<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Kurangnya informasi, misinformasi</span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;"></span></div>
<div class="MsoNormal">
</div>
<div class="MsoNormal">
<span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Faktor-faktor yang berhubungan : </span></div>
<div class="MsoNormal">
<span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Ketidakmampuan pemasukan atau mencerna makanan atau
mengabsorpsi zat-zat gizi berhubungan dengan faktor biologis, psikologis atau
ekonomi.</span></div>
<div class="MsoNormal">
</div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .75pt; mso-border-left-alt: solid black .75pt; mso-border-top-alt: solid black .75pt; padding: 0in 5.4pt 0in 5.4pt; width: 29.1%;" valign="top" width="29%"><div class="MsoNormal">
<b><span style="font-family: "Arial","sans-serif";">NOC :</span></b></div>
<div class="MsoNormal" style="margin-left: 39.7pt; mso-list: l4 level1 lfo6; tab-stops: list 39.7pt; text-indent: -.25in;">
<span style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif";">Nutritional
Status : food and Fluid Intake</span></div>
<div class="MsoNormal" style="margin-left: 39.7pt; mso-list: l4 level1 lfo6; tab-stops: list 39.7pt; text-indent: -.25in;">
<span style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif";">Nutritional
Status : nutrient Intake</span></div>
<div class="MsoNormal" style="margin-left: 21.7pt;">
</div>
<div class="MsoNormal">
<b><span style="font-family: "Arial","sans-serif";">Kriteria
Hasil :</span></b></div>
<div class="MsoNormal" style="margin-left: 30.7pt; mso-list: l3 level1 lfo7; tab-stops: list 30.7pt; text-indent: -.25in;">
<span style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif";">Adanya
peningkatan berat badan sesuai dengan tujuan</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; mso-list: l3 level1 lfo7; tab-stops: list 30.7pt; text-indent: -.25in;">
<span style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif";">Beratbadan
ideal sesuai dengan tinggi badan</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; mso-list: l3 level1 lfo7; tab-stops: list 30.7pt; text-indent: -.25in;">
<span style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif";">Mampumengidentifikasi
kebutuhan nutrisi</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; mso-list: l3 level1 lfo7; tab-stops: list 30.7pt; text-indent: -.25in;">
<span style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif";">Tidk
ada tanda tanda malnutrisi</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; mso-list: l3 level1 lfo7; tab-stops: list 30.7pt; text-indent: -.25in;">
<span style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif";">Menunjukkan
peningkatan fungsi pengecapan dari menelan</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; mso-list: l3 level1 lfo7; tab-stops: list 30.7pt; text-indent: -.25in;">
<span lang="NL" style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif";">Tidak terjadi penurunan berat badan yang berarti</span></div>
<div class="MsoNormal">
</div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .75pt; mso-border-left-alt: solid black .75pt; mso-border-top-alt: solid black .75pt; padding: 0in 5.4pt 0in 5.4pt; width: 35.98%;" valign="top" width="35%"><div class="MsoNormal">
<b><span style="font-family: "Arial","sans-serif";">NIC :</span></b></div>
<div class="MsoNormal">
<b><span style="font-family: "Arial Narrow","sans-serif";">Nutrition
Management</span></b></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l18 level1 lfo19; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Kaji adanya alergi makanan</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l18 level1 lfo19; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Kolaborasi dengan ahli gizi untuk menentukan jumlah kalori dan nutrisi
yang dibutuhkan pasien.</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l18 level1 lfo19; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Anjurkan pasien untuk
meningkatkan intake Fe</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l18 level1 lfo19; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Anjurkan pasien untuk
meningkatkan protein dan vitamin C</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l18 level1 lfo19; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Berikan substansi gula</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l18 level1 lfo19; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Yakinkan diet yang dimakan
mengandung tinggi serat untuk mencegah konstipasi</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l18 level1 lfo19; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Berikan makanan yang terpilih
( sudah dikonsultasikan dengan ahli gizi)</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l18 level1 lfo19; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Ajarkan pasien bagaimana membuat catatan makanan harian.</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l18 level1 lfo19; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor jumlah nutrisi dan
kandungan kalori</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l18 level1 lfo19; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Berikan informasi tentang kebutuhan nutrisi</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l18 level1 lfo19; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings;">§<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Kaji kemampuan pasien untuk mendapatkan nutrisi yang dibutuhkan</span></div>
<div class="MsoNormal">
<b><span style="font-family: "Arial Narrow","sans-serif";">Nutrition
Monitoring</span></b></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l11 level1 lfo20; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">BB pasien dalam batas normal</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l11 level1 lfo20; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor adanya penurunan berat badan</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l11 level1 lfo20; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor tipe dan jumlah
aktivitas yang biasa dilakukan</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l11 level1 lfo20; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="IT" style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span lang="IT" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor interaksi anak atau
orangtua selama makan</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l11 level1 lfo20; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor lingkungan selama makan</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l11 level1 lfo20; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Jadwalkan pengobatan dan tindakan tidak selama jam makan</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l11 level1 lfo20; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor kulit kering dan
perubahan pigmentasi</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l11 level1 lfo20; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor turgor kulit</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l11 level1 lfo20; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor kekeringan, rambut
kusam, dan mudah patah</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l11 level1 lfo20; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor mual dan muntah</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l11 level1 lfo20; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor kadar albumin, total
protein, Hb, dan kadar Ht</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l11 level1 lfo20; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor makanan kesukaan</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l11 level1 lfo20; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor pertumbuhan dan perkembangan</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l11 level1 lfo20; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor pucat, kemerahan,
dan kekeringan jaringan konjungtiva</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l11 level1 lfo20; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Monitor kalori dan intake nuntrisi</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l11 level1 lfo20; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Catat adanya edema, hiperemik, hipertonik papila lidah dan cavitas
oral.</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l11 level1 lfo20; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="IT" style="font-family: Wingdings; font-size: 11pt;">§<span style="font: 7pt "Times New Roman";"> </span></span><span lang="IT" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Catat jika lidah berwarna
magenta, scarlet</span><span lang="IT" style="font-family: "Arial","sans-serif"; font-size: 11pt;"></span></div>
<div class="MsoNormal">
</div>
<div class="MsoNormal">
</div>
</td>
</tr>
<tr style="mso-yfti-irow: 5;">
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .75pt; mso-border-top-alt: solid black .75pt; padding: 0in 5.4pt 0in 5.4pt; width: 4.38%;" valign="top" width="4%"><div align="center" class="MsoNormal" style="text-align: center;">
5</div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .75pt; mso-border-left-alt: solid black .75pt; mso-border-top-alt: solid black .75pt; padding: 0in 5.4pt 0in 5.4pt; width: 30.54%;" valign="top" width="30%"><div class="MsoNormal" style="line-height: 150%;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Cemas</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Definisi : </span></div>
<div class="MsoNormal" style="text-align: justify;">
<span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Perasaan gelisah yang
tak jelas dari ketidaknyamanan atau ketakutan yang disertai respon autonom
(sumner tidak spesifik atau tidak diketahui oleh individu); perasaan
keprihatinan disebabkan dari antisipasi terhadap bahaya. Sinyal ini merupakan
peringatan adanya ancaman yang akan datang dan memungkinkan individu untuk
mengambil langkah untuk menyetujui terhadap tindakan</span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;"></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Ditandai
dengan</span></div>
<div class="MsoNormal" style="margin-left: .5in; mso-list: l2 level1 lfo27; tab-stops: list .5in 81.0pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Symbol; font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Gelisah</span></div>
<div class="MsoNormal" style="margin-left: .5in; mso-list: l2 level1 lfo27; tab-stops: list .5in 81.0pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Symbol; font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Insomnia</span></div>
<div class="MsoNormal" style="margin-left: .5in; mso-list: l2 level1 lfo27; tab-stops: list .5in 81.0pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Symbol; font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Resah</span></div>
<div class="MsoNormal" style="margin-left: .5in; mso-list: l2 level1 lfo27; tab-stops: list .5in 81.0pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Symbol; font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Ketakutan</span></div>
<div class="MsoNormal" style="margin-left: .5in; mso-list: l2 level1 lfo27; tab-stops: list .5in 81.0pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Symbol; font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Sedih</span></div>
<div class="MsoNormal" style="margin-left: .5in; mso-list: l2 level1 lfo27; tab-stops: list .5in 81.0pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Symbol; font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Fokus pada diri</span></div>
<div class="MsoNormal" style="margin-left: .5in; mso-list: l2 level1 lfo27; tab-stops: list .5in 81.0pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Symbol; font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Kekhawatiran</span></div>
<div class="MsoNormal" style="margin-left: .5in; mso-list: l2 level1 lfo27; tab-stops: list .5in 81.0pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Symbol; font-size: 11pt;">-<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Cemas</span></div>
<div class="MsoNormal">
</div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .75pt; mso-border-left-alt: solid black .75pt; mso-border-top-alt: solid black .75pt; padding: 0in 5.4pt 0in 5.4pt; width: 29.1%;" valign="top" width="29%"><div class="MsoNormal">
<b><span style="font-family: "Arial","sans-serif";">NOC :</span></b></div>
<div class="MsoNormal" style="margin-left: 30.7pt; mso-list: l17 level1 lfo13; tab-stops: list 30.7pt; text-indent: -.25in;">
<span style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif";">Anxiety
control</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; mso-list: l17 level1 lfo13; tab-stops: list 30.7pt; text-indent: -.25in;">
<span style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif";">Coping</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; mso-list: l17 level1 lfo13; tab-stops: list 30.7pt; text-indent: -.25in;">
<span style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif";">Impulse
control</span></div>
<div class="MsoNormal">
<b><span style="font-family: "Arial","sans-serif";">Kriteria
Hasil :</span></b></div>
<div class="MsoNormal" style="margin-left: 30.7pt; mso-list: l5 level1 lfo14; tab-stops: list 30.7pt; text-indent: -.25in;">
<span lang="NL" style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif";">Klien mampu mengidentifikasi dan mengungkapkan gejala cemas</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; mso-list: l5 level1 lfo14; tab-stops: list 30.7pt; text-indent: -.25in;">
<span lang="NL" style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif";">Mengidentifikasi, mengungkapkan dan menunjukkan tehnik untuk mengontol
cemas</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; mso-list: l5 level1 lfo14; tab-stops: list 30.7pt; text-indent: -.25in;">
<span style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif";">Vital
sign dalam batas normal</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; mso-list: l5 level1 lfo14; tab-stops: list 30.7pt; text-indent: -.25in;">
<span style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif";">Postur
tubuh, ekspresi wajah, bahasa tubuh dan tingkat aktivitas menunjukkan
berkurangnya kecemasan</span></div>
<div class="MsoNormal">
</div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .75pt; mso-border-left-alt: solid black .75pt; mso-border-top-alt: solid black .75pt; padding: 0in 5.4pt 0in 5.4pt; width: 35.98%;" valign="top" width="35%"><div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<b><span style="font-family: "Arial","sans-serif";">NIC :</span></b></div>
<div class="MsoHeading7" style="line-height: normal;">
<span style="font-family: "Arial Narrow","sans-serif";">Anxiety
Reduction (penurunan kecemasan)</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l20 level1 lfo25; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Gunakan pendekatan yang menenangkan </span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l20 level1 lfo25; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Nyatakan dengan jelas harapan terhadap pelaku pasien</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l20 level1 lfo25; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Jelaskan semua prosedur dan apa yang dirasakan selama
prosedur</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l20 level1 lfo25; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="FR" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="FR" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Pahami prespektif pasien terhdap situasi stres</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l20 level1 lfo25; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Temani pasien untuk memberikan keamanan dan mengurangi
takut</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l20 level1 lfo25; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Berikan informasi faktual mengenai diagnosis, tindakan
prognosis </span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l20 level1 lfo25; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Dorong keluarga untuk menemani anak</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l20 level1 lfo25; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Lakukan back / neck rub</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l20 level1 lfo25; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Dengarkan dengan penuh perhatian</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l20 level1 lfo25; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Identifikasi tingkat kecemasan </span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l20 level1 lfo25; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Bantu pasien mengenal situasi yang menimbulkan
kecemasan</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l20 level1 lfo25; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Dorong pasien untuk mengungkapkan perasaan, ketakutan,
persepsi</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l20 level1 lfo25; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span lang="NL" style="font-family: Symbol; font-size: 11pt;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Instruksikan pasien menggunakan teknik relaksasi</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; mso-list: l20 level1 lfo25; tab-stops: list 21.65pt; text-align: justify; text-indent: -.25in;">
<span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Barikan obat untuk mengurangi kecemasan</span></div>
<div class="MsoNormal" style="margin-left: 3.65pt; text-align: justify;">
</div>
</td>
</tr>
<tr style="mso-yfti-irow: 6; mso-yfti-lastrow: yes;">
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .75pt; mso-border-top-alt: solid black .75pt; padding: 0in 5.4pt 0in 5.4pt; width: 4.38%;" valign="top" width="4%"><div align="center" class="MsoNormal" style="text-align: center;">
6</div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .75pt; mso-border-left-alt: solid black .75pt; mso-border-top-alt: solid black .75pt; padding: 0in 5.4pt 0in 5.4pt; width: 30.54%;" valign="top" width="30%"><div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt;">Kurang pengetahuan</span></div>
<div class="MsoNormal">
</div>
<div class="MsoNormal">
<span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Definisi : </span></div>
<div class="MsoNormal">
<span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Tidak adanya atau kurangnya informasi kognitif sehubungan dengan
topic spesifik.</span></div>
<div class="MsoNormal">
</div>
<div class="MsoNormal">
<span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Batasan karakteristik : memverbalisasikan adanya masalah,
ketidakakuratan mengikuti instruksi, perilaku tidak sesuai.</span></div>
<div class="MsoNormal">
</div>
<div class="MsoNormal">
<span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Faktor yang berhubungan : keterbatasan kognitif, interpretasi
terhadap informasi yang salah, kurangnya keinginan untuk mencari informasi,
tidak mengetahui sumber-sumber informasi.</span><span lang="NO-BOK"></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .75pt; mso-border-left-alt: solid black .75pt; mso-border-top-alt: solid black .75pt; padding: 0in 5.4pt 0in 5.4pt; width: 29.1%;" valign="top" width="29%"><div class="MsoNormal">
<b><span style="font-family: "Arial Narrow","sans-serif";">NOC
:</span></b></div>
<div class="MsoNormal" style="margin-left: 30.7pt; mso-list: l22 level1 lfo4; tab-stops: list 30.7pt; text-indent: -.25in;">
<span style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif";">Kowlwdge
: disease process</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; mso-list: l22 level1 lfo4; tab-stops: list 30.7pt; text-indent: -.25in;">
<span style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial Narrow","sans-serif";">Kowledge
: health Behavior</span></div>
<div class="MsoNormal">
<b><span style="font-family: "Arial Narrow","sans-serif";">Kriteria
Hasil :</span></b></div>
<div class="MsoNormal" style="margin-left: 30.7pt; mso-list: l7 level1 lfo5; tab-stops: list 30.7pt; text-indent: -.25in;">
<span lang="NL" style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif";">Pasien dan keluarga menyatakan pemahaman tentang penyakit, kondisi,
prognosis dan program pengobatan</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; mso-list: l7 level1 lfo5; tab-stops: list 30.7pt; text-indent: -.25in;">
<span lang="NL" style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif";">Pasien dan keluarga mampu melaksanakan prosedur yang dijelaskan secara
benar</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; mso-list: l7 level1 lfo5; tab-stops: list 30.7pt; text-indent: -.25in;">
<span lang="NL" style="font-family: Wingdings;">v<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NL" style="font-family: "Arial Narrow","sans-serif";">Pasien dan keluarga mampu menjelaskan kembali apa yang dijelaskan
perawat/tim kesehatan lainnya.</span></div>
<div class="MsoNormal">
</div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .75pt; mso-border-left-alt: solid black .75pt; mso-border-top-alt: solid black .75pt; padding: 0in 5.4pt 0in 5.4pt; width: 35.98%;" valign="top" width="35%"><div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<b><span style="font-family: "Arial","sans-serif";">NIC :</span></b></div>
<div class="MsoHeading7" style="line-height: normal;">
<span style="font-family: "Arial Narrow","sans-serif";">Teaching
: disease Process</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l10 level1 lfo22; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">1.<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Berikan penilaian
tentang tingkat pengetahuan pasien tentang proses penyakit yang spesifik </span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l10 level1 lfo22; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">2.<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Jelaskan patofisiologi
dari penyakit dan bagaimana hal ini berhubungan dengan anatomi dan fisiologi,
dengan cara yang tepat. </span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l10 level1 lfo22; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">3.<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Gambarkan tanda dan
gejala yang biasa muncul pada penyakit, dengan cara yang tepat </span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l10 level1 lfo22; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">4.<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Gambarkan proses
penyakit, dengan cara yang tepat </span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l10 level1 lfo22; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">5.<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Identifikasi kemungkinan
penyebab, dengna cara yang tepat </span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l10 level1 lfo22; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">6.<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Sediakan informasi pada
pasien tentang kondisi, dengan cara yang tepat </span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l10 level1 lfo22; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">7.<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Hindari jaminan yang
kosong </span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l10 level1 lfo22; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">8.<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Sediakan bagi keluarga
atau SO informasi tentang kemajuan pasien dengan cara yang tepat </span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l10 level1 lfo22; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">9.<span style="font: 7pt "Times New Roman";">
</span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Diskusikan perubahan gaya hidup yang mungkin
diperlukan untuk mencegah komplikasi di masa yang akan datang dan atau proses
pengontrolan penyakit </span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;"></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l10 level1 lfo22; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span style="font-size: 11pt;">10.<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Diskusikan pilihan
terapi atau penanganan</span><span style="font-size: 11pt;"></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l10 level1 lfo22; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">11.<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Dukung pasien untuk
mengeksplorasi atau mendapatkan second opinion dengan cara yang tepat atau
diindikasikan </span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l10 level1 lfo22; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">12.<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Eksplorasi kemungkinan
sumber atau dukungan, dengan cara yang tepat </span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l10 level1 lfo22; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="IT" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">13.<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Rujuk pasien pada grup
atau agensi di komunitas lokal, dengan cara yang tepat</span><span lang="IT" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;"></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; mso-list: l10 level1 lfo22; tab-stops: list 21.55pt; text-align: justify; text-indent: -.25in;">
<span lang="IT">14.<span style="font: 7pt "Times New Roman";"> </span></span><span lang="NO-BOK" style="font-family: "Arial Narrow","sans-serif"; font-size: 11pt;">Instruksikan pasien
mengenai tanda dan gejala untuk melaporkan pada pemberi perawatan kesehatan,
dengan cara yang tepat</span><span lang="IT"></span></div>
<div class="MsoNormal">
</div>
</td></tr>
</tbody></table>
ERFANSYAH. HRhttp://www.blogger.com/profile/07497970584312798191noreply@blogger.com0tag:blogger.com,1999:blog-2228299828902052163.post-49666749492979188042012-11-21T05:49:00.003-08:002013-03-11T10:03:24.318-07:00Asuhan Keperawatan Atresia Anii Aplikasi NIC, NOC, NANDA<h3 class="post-title entry-title" itemprop="name" style="font-family: Georgia,"Times New Roman",serif;">
<span style="font-size: small;">
Asuhan Keperawatan Atresia Anii Aplikasi NIC, NOC, NANDA
</span></h3>
<div style="font-family: Georgia,"Times New Roman",serif;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoHeading9" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 27pt; text-indent: -0.25in;">
<span style="font-size: small;">A.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Masalah
yang lazim muncul pada klien</span></div>
<div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small; line-height: 150%;">1.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small; line-height: 150%;">Cemas b/d pembedahan dan mempunyai anak yang tidak
sempurna</span></div>
<div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small; line-height: 150%;">2.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small; line-height: 150%;">Inkontinensia Bowel b/d struktur anus yang tidak komplit</span></div>
<div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small; line-height: 150%;">3.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small; line-height: 150%;">Kerusakan integritas kulit b/d kolostomi</span></div>
<div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small; line-height: 150%;">4.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small; line-height: 150%;">Kurang pengetahuan b/d perawatan di rumah dan pembedahan</span></div>
<div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small; line-height: 150%;">5.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small; line-height: 150%;">Ketidakseimbangan nutrisi kurang dari kebutuhan tubuh b/d
ketidakmampuan mencerna makanan</span></div>
<div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small; line-height: 150%;">6.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small; line-height: 150%;">Resiko infeksi b/d pembedahan</span></div>
<div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small; line-height: 150%;">7.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small; line-height: 150%;">Resiko defisit volume cairan b/d pengurangan intake
cairan</span></div>
<h1 style="font-family: Georgia,"Times New Roman",serif; line-height: 150%;">
<span style="font-size: small;">
B.</span><span style="font-size: small;"> Discharge Planning</span></h1>
<div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small; line-height: 150%;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small; line-height: 150%;">Berikan puian saat melakukan perawatan dan jawab
pertanyaan secara jujur apa yang dibutuhkan keluarga</span></div>
<div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small; line-height: 150%;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small; line-height: 150%;">Ajarkan mengenai tanda dan gejala infeksi (demam,
kemerahan di daerah luka, terasa panas)</span></div>
<div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small; line-height: 150%;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small; line-height: 150%;">Ajarkan bagaimana menganai pengamanan pada bayi dan
melakukan dilatasi anal</span></div>
<div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small; line-height: 150%;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small; line-height: 150%;">Berikan instruksi secara tertulis dan verbal tentang alat
alat yang dibutuhkan untu perawatan di rumah</span></div>
<div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-size: small; line-height: 150%;">Tekankan tetap
mengadakan stimulasi pada bayi untuk mensupport tumbuh kembang</span></div>
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: medium none; font-family: Georgia,"Times New Roman",serif; width: 100%;"><tbody>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">No</span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 30.86%;" valign="top" width="30%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">Diagnosa
keperawatan</span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 28.56%;" valign="top" width="28%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">Tujuan
dan Kriteria Hasil</span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 35.38%;" valign="top" width="35%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">Intervensi</span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">1</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 30.86%;" valign="top" width="30%"><div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;">Cemas
b/d pembedahan dan mempunyai anak yang tidak sempurna</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span lang="NO-BOK" style="font-size: small;">Definisi : </span></div>
<div class="MsoNormal" style="text-align: justify;">
<span lang="NO-BOK" style="font-size: small;">Perasaan gelisah yang
tak jelas dari ketidaknyamanan atau ketakutan yang disertai respon autonom
(sumner tidak spesifik atau tidak diketahui oleh individu); perasaan
keprihatinan disebabkan dari antisipasi terhadap bahaya. Sinyal ini merupakan
peringatan adanya ancaman yang akan datang dan memungkinkan individu untuk
mengambil langkah untuk menyetujui terhadap tindakan</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;">Ditandai
dengan</span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-size: small;">Gelisah</span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-size: small;">Insomnia</span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-size: small;">Resah</span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-size: small;">Ketakutan</span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-size: small;">Sedih</span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-size: small;">Fokus pada diri</span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-size: small;">Kekhawatiran</span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-size: small;">Cemas</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 28.56%;" valign="top" width="28%"><div class="MsoNormal">
<span style="font-size: small;"><b>NOC :</b></span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Anxiety
control</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Coping</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Impulse
control</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><b>Kriteria
Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Klien
mampu mengidentifikasi dan mengungkapkan gejala cemas</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Mengidentifikasi,
mengungkapkan dan menunjukkan tehnik untuk mengontol cemas</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Vital
sign dalam batas normal</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Postur
tubuh, ekspresi wajah, bahasa tubuh dan tingkat aktivitas menunjukkan
berkurangnya kecemasan</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 35.38%;" valign="top" width="35%"><div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>NIC :</b></span></div>
<div class="MsoHeading7" style="line-height: normal;">
<span style="font-size: small;">Anxiety
Reduction (penurunan kecemasan)</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Gunakan pendekatan yang menenangkan </span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Nyatakan dengan jelas harapan terhadap pelaku pasien</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Jelaskan semua prosedur dan apa yang dirasakan selama
prosedur</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="FR" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="FR" style="font-size: small;">Pahami prespektif pasien terhdap situasi stres</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Temani pasien untuk memberikan keamanan dan mengurangi
takut</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Berikan informasi faktual mengenai diagnosis, tindakan
prognosis </span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Dorong keluarga untuk menemani anak</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Lakukan back / neck rub</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Dengarkan dengan penuh perhatian</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Identifikasi tingkat kecemasan </span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Bantu pasien mengenal situasi yang menimbulkan
kecemasan</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Dorong pasien untuk mengungkapkan perasaan, ketakutan,
persepsi</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Instruksikan pasien menggunakan teknik relaksasi</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Barikan obat untuk mengurangi kecemasan</span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">2</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 30.86%;" valign="top" width="30%"><div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;">Inkontinensia
Bowel b/d struktur anus yang tidak komplit</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 28.56%;" valign="top" width="28%"><div class="MsoBodyTextIndent" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>NOC:</b></span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Bowel
Continence</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Bowel
Elimination</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>BAB
teratur, mulai dari setiap hari sampai 3-5 hari</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Defekasi
lunak, feses berbentuk</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Penurunan
insiden inkontinensia usus</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 35.38%;" valign="top" width="35%"><div class="MsoBodyTextIndent" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>NIC :</b></span></div>
<div class="MsoBodyTextIndent" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>Bowel
Inkontinence care</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -12.65pt;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Perkirakan penyebab fisik dan psikologi dari
inkontimemsia fekal</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -12.65pt;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Jelaskan penyebab masalah dan rasional dari
tindakan</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -12.65pt;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Jelaskan tujuan dari managemen bowel pada
pasien/keluarga</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -12.65pt;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Diskusikan prosedur dan criteria hasil yang
diharapkan bersama pasien</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -12.65pt;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Instruksikan pasien/keluarga untuk mencatat
keluaran feses</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -12.65pt;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Cuci area perianal dengansabun dan air
lalukeringkan</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -12.65pt;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Jaga kebersihan baju dan tempat tidur</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -12.65pt;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Lakukan program latihan BAB</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -12.65pt;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Monitor efek samping pengobatan.</span></div>
<div class="MsoHeading7" style="line-height: normal;">
<span style="font-size: small;">Bowel
Training</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Rencanakan program BAB dengan pasien dan pasien
yang lain</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Konsul ke dokter jika pasien memerlukan
suppositoria</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Ajarkan ke pasien/keluarga tentang prinsip
latihan BAB</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Anjurkan pasien untuk cukup minum</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Dorong pasien untuk cukup latihan</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Jaga privasi klien</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Kolaborasi pemberian suppositoria jika
memungkinkan</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-size: small;">Evaluasi
status BAB secara rutin</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-size: small;">Modifikasi
program BAB jika diperlukan</span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">3</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 30.86%;" valign="top" width="30%"><div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;">Kerusakan
integritas kulit b/d kolostomi</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span lang="NO-BOK" style="font-size: small;">Definisi : Perubahan
pada epidermis dan dermis</span></div>
<div class="MsoNormal">
<span lang="NO-BOK" style="font-size: small;">Batasan karakteristik : </span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Gangguan pada bagian tubuh </span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Kerusakan lapisa kulit (dermis) </span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Gangguan permukaan kulit (epidermis)</span></div>
<div class="MsoNormal">
<span lang="NO-BOK" style="font-size: small;">Faktor yang berhubungan : </span></div>
<div class="MsoNormal">
<span lang="NO-BOK" style="font-size: small;">Eksternal : </span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Hipertermia atau hipotermia </span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Substansi kimia </span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Kelembaban udara </span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Faktor mekanik (misalnya : alat yang dapat
menimbulkan luka, tekanan, restraint)</span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Immobilitas fisik </span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Radiasi </span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Usia yang ekstrim </span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Kelembaban kulit </span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Obat-obatan </span></div>
<div class="MsoNormal">
<span lang="NO-BOK" style="font-size: small;">Internal : </span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Perubahan status metabolik </span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Tulang menonjol </span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Defisit imunologi </span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Faktor yang berhubungan dengan perkembangan </span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Perubahan sensasi </span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Perubahan status nutrisi (obesitas,
kekurusan) </span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Perubahan status cairan </span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Perubahan pigmentasi </span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Perubahan sirkulasi </span></div>
<div class="MsoNormal" style="text-align: justify;">
<span lang="NO-BOK" style="font-size: small;">Perubahan turgor (elastisitas kulit)</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 28.56%;" valign="top" width="28%"><div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NOC </b>:
Tissue Integrity : Skin and Mucous Membranes</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 39.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Integritas
kulit yang baik bisa dipertahankan (sensasi, elastisitas, temperatur,
hidrasi, pigmentasi)</span></div>
<div class="MsoNormal" style="margin-left: 39.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Tidak
ada luka/lesi pada kulit</span></div>
<div class="MsoNormal" style="margin-left: 39.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Perfusi
jaringan baik</span></div>
<div class="MsoNormal" style="margin-left: 39.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Menunjukkan
pemahaman dalam proses perbaikan kulit dan mencegah terjadinya sedera
berulang</span></div>
<div class="MsoNormal" style="margin-left: 39.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Mampu
melindungi kulit dan mempertahankan kelembaban kulit dan perawatan alami</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 35.38%;" valign="top" width="35%"><div class="MsoNormal">
<span style="font-size: small;"><b>NIC </b>:<b> Pressure Management</b></span></div>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;">Anjurkan pasien untuk menggunakan pakaian
yang longgar</span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;">Hindari kerutan padaa tempat tidur</span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;">Jaga kebersihan kulit agar tetap bersih dan
kering</span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;">Mobilisasi pasien (ubah posisi pasien)
setiap dua jam sekali</span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;">Monitor kulit akan adanya kemerahan </span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;">Oleskan lotion atau minyak/baby oil pada
derah yang tertekan </span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;">Monitor aktivitas dan mobilisasi pasien</span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;">Monitor status nutrisi pasien</span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;">pasien dengan sabun dan air hangat</span></li>
</ul>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">4</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 30.86%;" valign="top" width="30%"><div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;">Kurang
pengetahuan b/d perawatan di rumah dan pembedahan.</span></div>
<div class="MsoNormal">
<span lang="NO-BOK" style="font-size: small;">Definisi : </span></div>
<div class="MsoNormal">
<span lang="NO-BOK" style="font-size: small;">Tidak adanya atau kurangnya informasi kognitif sehubungan dengan
topic spesifik.</span></div>
<div class="MsoNormal">
<span lang="NO-BOK" style="font-size: small;">Batasan karakteristik : memverbalisasikan adanya masalah,
ketidakakuratan mengikuti instruksi, perilaku tidak sesuai.</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span lang="NO-BOK" style="font-size: small;">Faktor yang berhubungan
: keterbatasan kognitif, interpretasi terhadap informasi yang salah,
kurangnya keinginan untuk mencari informasi, tidak mengetahui sumber-sumber
informasi.</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 28.56%;" valign="top" width="28%"><div class="MsoNormal">
<span style="font-size: small;"><b>NOC :</b></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.3in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Kowlwdge : disease process</span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.3in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Kowledge : health Behavior</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><b>Kriteria
Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Pasien
dan keluarga menyatakan pemahaman tentang penyakit, kondisi, prognosis dan
program pengobatan</span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Pasien
dan keluarga mampu melaksanakan prosedur yang dijelaskan secara benar</span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Pasien
dan keluarga mampu menjelaskan kembali apa yang dijelaskan perawat/tim
kesehatan lainnya</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 35.38%;" valign="top" width="35%"><div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>NIC :</b></span></div>
<div class="MsoHeading7" style="line-height: normal;">
<span style="font-size: small;">Teaching
: disease Process</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK" style="font-size: small;">Berikan penilaian
tentang tingkat pengetahuan pasien tentang proses penyakit yang spesifik </span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK" style="font-size: small;">Jelaskan patofisiologi
dari penyakit dan bagaimana hal ini berhubungan dengan anatomi dan fisiologi,
dengan cara yang tepat. </span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK" style="font-size: small;">Gambarkan tanda dan
gejala yang biasa muncul pada penyakit, dengan cara yang tepat </span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK" style="font-size: small;">Gambarkan proses
penyakit, dengan cara yang tepat </span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK" style="font-size: small;">identifikasi kemungkinan
penyebab, dengna cara yang tepat </span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK" style="font-size: small;">Sediakan informasi pada
pasien tentang kondisi, dengan cara yang tepat </span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK" style="font-size: small;">Hindari jaminan yang
kosong </span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK" style="font-size: small;">Sediakan bagi keluarga
atau SO informasi tentang kemajuan pasien dengan cara yang tepat </span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK" style="font-size: small;">Diskusikan perubahan
gaya hidup yang mungkin diperlukan untuk mencegah komplikasi di masa yang
akan datang dan atau proses pengontrolan penyakit </span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK" style="font-size: small;">Diskusikan pilihan
terapi atau penanganan</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK" style="font-size: small;">Dukung pasien untuk
mengeksplorasi atau mendapatkan second opinion dengan cara yang tepat atau
diindikasikan </span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK" style="font-size: small;">Eksplorasi kemungkinan
sumber atau dukungan, dengan cara yang tepat </span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Rujuk pasien pada grup atau agensi di komunitas
lokal, dengan cara yang tepat</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Instruksikan pasien mengenai tanda dan gejala untuk
melaporkan pada pemberi</span><span lang="NO-BOK" style="font-size: small;"> </span><span lang="NO-BOK" style="font-size: small;">perawatan kesehatan, dengan cara yang tepat.</span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">5</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 30.86%;" valign="top" width="30%"><div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;">Ketidakseimbangan
nutrisi kurang dari kebutuhan tubuh b/d ketidakmampuan mencerna makanan</span></div>
<div class="MsoNormal">
<span lang="NO-BOK" style="font-size: small;">Definisi : Intake nutrisi tidak cukup untuk
keperluan metabolisme tubuh.</span></div>
<div class="MsoNormal">
<span lang="NO-BOK" style="font-size: small;">Batasan karakteristik : </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Berat badan 20 % atau lebih di bawah ideal </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Dilaporkan adanya intake makanan yang kurang
dari RDA (Recomended Daily Allowance) </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Membran mukosa dan konjungtiva pucat </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Kelemahan otot yang digunakan untuk
menelan/mengunyah </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Luka, inflamasi pada rongga mulut </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Mudah merasa kenyang, sesaat setelah
mengunyah makanan </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Dilaporkan atau fakta adanya kekurangan
makanan </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Dilaporkan adanya perubahan sensasi rasa </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Perasaan ketidakmampuan untuk mengunyah
makanan </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Miskonsepsi </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Kehilangan BB dengan makanan cukup </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Keengganan untuk makan </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Kram pada abdomen </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Tonus otot jelek </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Nyeri abdominal dengan atau tanpa patologi </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Kurang berminat terhadap makanan</span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Pembuluh darah kapiler mulai rapuh </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Diare dan atau steatorrhea </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Kehilangan rambut yang cukup banyak (rontok) </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK" style="font-size: small;">Suara usus hiperaktif</span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK" style="font-size: small;">Kurangnya informasi, misinformasi</span></div>
<div class="MsoNormal">
<span lang="NO-BOK" style="font-size: small;">Faktor-faktor yang berhubungan : </span></div>
<div class="MsoNormal" style="text-align: justify;">
<span lang="NO-BOK" style="font-size: small;">Ketidakmampuan pemasukan atau mencerna makanan atau mengabsorpsi zat-zat
gizi berhubungan dengan faktor biologis, psikologis atau ekonomi.</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 28.56%;" valign="top" width="28%"><div class="MsoNormal">
<span style="font-size: small;"><b>NOC :</b></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Nutritional Status : food and
Fluid Intake</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><b>Kriteria
Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Adanya peningkatan berat
badan sesuai dengan tujuan</span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Berat badan ideal sesuai
dengan tinggi badan</span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Mampu mengidentifikasi
kebutuhan nutrisi</span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Tidak ada tanda tanda
malnutrisi</span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Tidak terjadi penurunan berat
badan yang berarti</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 35.38%;" valign="top" width="35%"><div class="MsoNormal">
<span style="font-size: small;"><b>Nutrition
Management</b></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Kaji adanya alergi makanan</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Kolaborasi dengan ahli gizi untuk menentukan jumlah kalori dan nutrisi
yang dibutuhkan pasien.</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Anjurkan pasien untuk meningkatkan intake Fe</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Anjurkan pasien untuk meningkatkan protein dan vitamin C</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Berikan substansi gula</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Yakinkan diet yang dimakan mengandung tinggi serat untuk mencegah
konstipasi</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Berikan makanan yang terpilih ( sudah dikonsultasikan dengan ahli
gizi)</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Ajarkan pasien bagaimana membuat catatan makanan harian.</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Monitor jumlah nutrisi dan kandungan kalori</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Berikan informasi tentang kebutuhan nutrisi</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Kaji kemampuan pasien untuk mendapatkan nutrisi yang dibutuhkan</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><b>Nutrition
Monitoring</b></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">BB pasien dalam batas normal</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Monitor adanya penurunan berat badan</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Monitor tipe dan jumlah aktivitas yang biasa dilakukan</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Monitor interaksi anak atau orangtua selama makan</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Monitor lingkungan selama makan</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Jadwalkan pengobatan dan
tindakan tidak selama jam makan</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Monitor kulit kering dan perubahan pigmentasi</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Monitor turgor kulit</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Monitor kekeringan, rambut kusam, dan mudah patah</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Monitor mual dan muntah</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Monitor kadar albumin, total protein, Hb, dan kadar Ht</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Monitor makanan kesukaan</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Monitor pertumbuhan dan perkembangan</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Monitor pucat, kemerahan, dan kekeringan jaringan konjungtiva</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Monitor kalori dan intake nuntrisi</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-size: small;">Catat adanya edema,
hiperemik, hipertonik papila lidah dan cavitas oral.</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-size: small;">Catat jika lidah
berwarna magenta, scarlet</span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">6</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 30.86%;" valign="top" width="30%"><div class="MsoNormal">
<span style="font-size: small;">Resiko infeksi b/d pembedahan</span></div>
<div class="MsoNormal">
<span lang="NO-BOK" style="font-size: small;">Definisi : Peningkatan resiko masuknya organisme patogen</span></div>
<div class="MsoNormal">
<span lang="NO-BOK" style="font-size: small;">Faktor-faktor resiko : </span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Prosedur Infasif</span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Ketidakcukupan pengetahuan untuk menghindari
paparan patogen </span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Trauma </span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Kerusakan jaringan dan peningkatan paparan
lingkungan </span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Ruptur membran amnion</span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Agen farmasi (imunosupresan)</span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Malnutrisi </span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Peningkatan paparan lingkungan patogen </span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Imonusupresi </span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Ketidakadekuatan imum buatan </span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Tidak adekuat pertahanan sekunder (penurunan Hb,
Leukopenia, penekanan respon inflamasi)</span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Tidak adekuat pertahanan tubuh primer (kulit tidak
utuh, trauma jaringan, penurunan kerja silia, cairan tubuh statis, perubahan
sekresi pH, perubahan peristaltik)</span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Penyakit kronik</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 28.56%;" valign="top" width="28%"><div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NOC : </b></span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Immune
Status</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Knowledge
: Infection control</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Risk
control</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Klien
bebas dari tanda dan gejala infeksi</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Mendeskripsikan
proses penularan penyakit, factor yang mempengaruhi penularan serta
penatalaksanaannya,</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Menunjukkan
kemampuan untuk mencegah timbulnya infeksi</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Jumlah
leukosit dalam batas normal</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Menunjukkan
perilaku hidup sehat</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 35.38%;" valign="top" width="35%"><div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NIC :</b></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Infection Control (Kontrol infeksi)</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="FR" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="FR" style="font-size: small;">Bersihkan lingkungan setelah dipakai pasien lain</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="FR" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="FR" style="font-size: small;">Pertahankan teknik isolasi</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="FR" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="FR" style="font-size: small;">Batasi pengunjung bila perlu</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Instruksikan pada pengunjung untuk mencuci tangan saat
berkunjung dan setelah berkunjung meninggalkan pasien</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Gunakan sabun antimikrobia untuk cuci tangan</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Cuci tangan setiap sebelum dan sesudah tindakan
kperawtan</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Gunakan baju, sarung tangan sebagai alat pelindung</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Pertahankan lingkungan aseptik selama pemasangan alat</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Ganti letak IV perifer dan line central dan dressing
sesuai dengan petunjuk umum</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Gunakan kateter intermiten untuk menurunkan infeksi
kandung kencing </span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Tingktkan intake nutrisi</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Berikan terapi antibiotik bila perlu</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Infection Protection (proteksi terhadap infeksi)</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Monitor tanda dan gejala infeksi sistemik dan lokal</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Monitor hitung granulosit, WBC</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Monitor kerentanan terhadap infeksi</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Batasi pengunjung</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Saring pengunjung terhadap penyakit menular</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Partahankan teknik aspesis pada pasien yang beresiko</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Pertahankan teknik isolasi k/p</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Berikan perawatan kuliat pada area epidema</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Inspeksi kulit dan membran mukosa terhadap kemerahan,
panas, drainase</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Ispeksi kondisi luka / insisi bedah</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Dorong masukkan nutrisi yang cukup</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Dorong masukan cairan</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Dorong istirahat</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Instruksikan pasien untuk minum antibiotik sesuai resep</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Ajarkan pasien dan keluarga tanda dan gejala infeksi</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Ajarkan cara menghindari infeksi</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Laporkan kecurigaan infeksi</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Laporkan kultur positif</span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">7</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 30.86%;" valign="top" width="30%"><div class="MsoBodyText3">
<span style="font-size: small;">Resiko defisit volume cairan b/d
pengurangan intake cairan</span></div>
<div class="MsoNormal">
<span lang="NO-BOK" style="font-size: small;">Definisi : Penurunan cairan intravaskuler,
interstisial, dan/atau intrasellular. Ini mengarah ke dehidrasi, kehilangan
cairan dengan pengeluaran sodium</span></div>
<div class="MsoNormal">
<span style="font-size: small;">Batasan
Karakteristik : </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Kelemahan </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Haus </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Penurunan turgor kulit/lidah </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-size: small;">Membran mukosa/kulit kering </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Peningkatan denyut nadi, penurunan tekanan
darah, penurunan volume/tekanan nadi </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Pengisian vena menurun </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Perubahan status mental</span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Konsentrasi urine meningkat </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span lang="NO-BOK" style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Temperatur tubuh meningkat </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK" style="font-size: small;">Hematokrit meninggi </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK" style="font-size: small;">Kehilangan berat badan seketika (kecuali pada third spacing)</span></div>
<div class="MsoNormal">
<span lang="NO-BOK" style="font-size: small;">Faktor-faktor yang berhubungan: </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK" style="font-size: small;">Kehilangan volume cairan secara aktif </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK" style="font-size: small;">Kegagalan mekanisme pengaturan</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 28.56%;" valign="top" width="28%"><div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NOC: </b></span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Fluid
balance</span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Hydration</span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Nutritional
Status : Food and Fluid Intake</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Mempertahankan
urine output sesuai dengan usia dan BB, BJ urine normal, HT normal</span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Tekanan
darah, nadi, suhu tubuh dalam batas normal</span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Tidak
ada tanda tanda dehidrasi, Elastisitas turgor kulit baik, membran mukosa
lembab, tidak ada rasa haus yang berlebihan</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 35.38%;" valign="top" width="35%"><div class="MsoHeading9">
<span style="font-size: small;">Fluid management</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Timbang popok/pembalut jika diperlukan </span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Pertahankan catatan intake dan output yang akurat</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Monitor status hidrasi ( kelembaban membran mukosa,
nadi adekuat, tekanan darah ortostatik ), jika diperlukan</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Monitor vital sign</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Monitor masukan makanan / cairan dan hitung intake
kalori harian</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Kolaborasi pemberian cairan IV </span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Monitor status nutrisi</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Kolaborasikan pemberian cairan</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Berikan cairan IV pada suhu ruangan </span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Dorong masukan oral</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Berikan penggantian nesogatrik sesuai output</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Dorong keluarga untuk membantu pasien makan</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-size: small;">Tawarkan snack ( jus
buah, buah segar )</span><span lang="NL" style="font-size: small;"></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span lang="NL" style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Kolaborasi dokter jika tanda cairan berlebih muncul
meburuk </span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Atur kemungkinan tranfusi</span><span style="font-size: small;"></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL" style="font-size: small;">Persiapan untuk tranfusi</span></div>
<div class="MsoNormal">
</div>
</td></tr>
</tbody></table>
ERFANSYAH. HRhttp://www.blogger.com/profile/07497970584312798191noreply@blogger.com0tag:blogger.com,1999:blog-2228299828902052163.post-23814681754452762292012-11-21T05:47:00.001-08:002013-03-11T10:03:24.309-07:00Asuhan Keperawatan Atresia Anii Aplikasi NIC, NOC, NANDA<h3 class="post-title entry-title" itemprop="name" style="font-family: Georgia,"Times New Roman",serif;">
<span style="font-size: small;">
Asuhan Keperawatan Atresia Anii Aplikasi NIC, NOC, NANDA
</span></h3>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span>
<div align="center" class="MsoBodyText2" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; text-align: center;">
<span style="font-size: small;"><b><span style="line-height: 150%;"></span></b></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoBodyText2" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%;">
<span style="font-size: small;"><br /></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoHeading9" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 27pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>A.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span>Masalah
yang lazim muncul pada klien</span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>1.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="line-height: 150%;">Cemas b/d pembedahan dan mempunyai anak yang tidak
sempurna</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>2.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="line-height: 150%;">Inkontinensia Bowel b/d struktur anus yang tidak komplit</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>3.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="line-height: 150%;">Kerusakan integritas kulit b/d kolostomi</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>4.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="line-height: 150%;">Kurang pengetahuan b/d perawatan di rumah dan pembedahan</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>5.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="line-height: 150%;">Ketidakseimbangan nutrisi kurang dari kebutuhan tubuh b/d
ketidakmampuan mencerna makanan</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>6.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="line-height: 150%;">Resiko infeksi b/d pembedahan</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>7.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="line-height: 150%;">Resiko defisit volume cairan b/d pengurangan intake
cairan</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><h1 style="font-family: Georgia,"Times New Roman",serif; line-height: 150%;">
<span style="font-size: small;">
B.<span> </span>Discharge Planning</span></h1>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="line-height: 150%;">Berikan puian saat melakukan perawatan dan jawab
pertanyaan secara jujur apa yang dibutuhkan keluarga</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="line-height: 150%;">Ajarkan mengenai tanda dan gejala infeksi (demam,
kemerahan di daerah luka, terasa panas)</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="line-height: 150%;">Ajarkan bagaimana menganai pengamanan pada bayi dan
melakukan dilatasi anal</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="line-height: 150%;">Berikan instruksi secara tertulis dan verbal tentang alat
alat yang dibutuhkan untu perawatan di rumah</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="line-height: 150%;">Tekankan tetap
mengadakan stimulasi pada bayi untuk mensupport tumbuh kembang</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt;">
<span style="font-size: small;"><br /></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span>
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: medium none; font-family: Georgia,"Times New Roman",serif; width: 100%;"><tbody>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>No</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 30.86%;" valign="top" width="30%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>Diagnosa
keperawatan</span></span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 28.56%;" valign="top" width="28%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>Tujuan
dan Kriteria Hasil</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 35.38%;" valign="top" width="35%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>Intervensi</span></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
1</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 30.86%;" valign="top" width="30%">
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><span>Cemas
b/d pembedahan dan mempunyai anak yang tidak sempurna</span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : </span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><span lang="NO-BOK">Perasaan gelisah yang
tak jelas dari ketidaknyamanan atau ketakutan yang disertai respon autonom
(sumner tidak spesifik atau tidak diketahui oleh individu); perasaan
keprihatinan disebabkan dari antisipasi terhadap bahaya. Sinyal ini merupakan
peringatan adanya ancaman yang akan datang dan memungkinkan individu untuk
mengambil langkah untuk menyetujui terhadap tindakan</span><span></span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><span>Ditandai
dengan</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Gelisah</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Insomnia</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Resah</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Ketakutan</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Sedih</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Fokus pada diri</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Kekhawatiran</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Cemas</span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 28.56%;" valign="top" width="28%">
<div class="MsoNormal">
<span style="font-size: small;"><b>NOC :</b></span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Anxiety
control</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Coping</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Impulse
control</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><b>Kriteria
Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Klien
mampu mengidentifikasi dan mengungkapkan gejala cemas</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Mengidentifikasi,
mengungkapkan dan menunjukkan tehnik untuk mengontol cemas</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Vital
sign dalam batas normal</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Postur
tubuh, ekspresi wajah, bahasa tubuh dan tingkat aktivitas menunjukkan
berkurangnya kecemasan</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 35.38%;" valign="top" width="35%">
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>NIC :</b></span></div>
<div class="MsoHeading7" style="line-height: normal;">
<span style="font-size: small;">
Anxiety
Reduction (penurunan kecemasan)</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Gunakan pendekatan yang menenangkan </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Nyatakan dengan jelas harapan terhadap pelaku pasien</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Jelaskan semua prosedur dan apa yang dirasakan selama
prosedur</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Pahami prespektif pasien terhdap situasi stres</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Temani pasien untuk memberikan keamanan dan mengurangi
takut</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Berikan informasi faktual mengenai diagnosis, tindakan
prognosis </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Dorong keluarga untuk menemani anak</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Lakukan back / neck rub</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Dengarkan dengan penuh perhatian</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Identifikasi tingkat kecemasan </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Bantu pasien mengenal situasi yang menimbulkan
kecemasan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Dorong pasien untuk mengungkapkan perasaan, ketakutan,
persepsi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Instruksikan pasien menggunakan teknik relaksasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Barikan obat untuk mengurangi kecemasan</span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
2</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 30.86%;" valign="top" width="30%">
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><span>Inkontinensia
Bowel b/d struktur anus yang tidak komplit</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 28.56%;" valign="top" width="28%">
<div class="MsoBodyTextIndent" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>NOC:</b></span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Bowel
Continence</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Bowel
Elimination</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>BAB
teratur, mulai dari setiap hari sampai 3-5 hari</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Defekasi
lunak, feses berbentuk</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Penurunan
insiden inkontinensia usus</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 35.38%;" valign="top" width="35%">
<div class="MsoBodyTextIndent" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>NIC :</b></span></div>
<div class="MsoBodyTextIndent" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>Bowel
Inkontinence care</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -12.65pt;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Perkirakan penyebab fisik dan psikologi dari
inkontimemsia fekal</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -12.65pt;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Jelaskan penyebab masalah dan rasional dari
tindakan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -12.65pt;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Jelaskan tujuan dari managemen bowel pada
pasien/keluarga</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -12.65pt;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Diskusikan prosedur dan criteria hasil yang
diharapkan bersama pasien</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -12.65pt;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Instruksikan pasien/keluarga untuk mencatat
keluaran feses</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -12.65pt;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Cuci area perianal dengansabun dan air
lalukeringkan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -12.65pt;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Jaga kebersihan baju dan tempat tidur</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -12.65pt;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Lakukan program latihan BAB</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -12.65pt;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor efek samping pengobatan.</span><span></span></span></div>
<div class="MsoBodyTextIndent" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoHeading7" style="line-height: normal;">
<span style="font-size: small;">
Bowel
Training</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Rencanakan program BAB dengan pasien dan pasien
yang lain</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Konsul ke dokter jika pasien memerlukan
suppositoria</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Ajarkan ke pasien/keluarga tentang prinsip
latihan BAB</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Anjurkan pasien untuk cukup minum</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Dorong pasien untuk cukup latihan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Jaga privasi klien</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Kolaborasi pemberian suppositoria jika
memungkinkan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Evaluasi
status BAB secara rutin</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Modifikasi
program BAB jika diperlukan</span></span></div>
<div class="MsoNormal" style="margin-left: 3.65pt;">
<span style="font-size: small;"><br /></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
3</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 30.86%;" valign="top" width="30%">
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><span>Kerusakan
integritas kulit b/d kolostomi</span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : Perubahan
pada epidermis dan dermis</span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Batasan karakteristik : </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Gangguan pada bagian tubuh </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kerusakan lapisa kulit (dermis) </span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Gangguan permukaan kulit (epidermis)</span><span></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Faktor yang berhubungan : </span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Eksternal : </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Hipertermia atau hipotermia </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Substansi kimia </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kelembaban udara </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Faktor mekanik (misalnya : alat yang dapat
menimbulkan luka, tekanan, restraint)</span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Immobilitas fisik </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Radiasi </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Usia yang ekstrim </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kelembaban kulit </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Obat-obatan </span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Internal : </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perubahan status metabolik </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Tulang menonjol </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Defisit imunologi </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Faktor yang berhubungan dengan perkembangan </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perubahan sensasi </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perubahan status nutrisi (obesitas,
kekurusan) </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perubahan status cairan </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perubahan pigmentasi </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perubahan sirkulasi </span><span></span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><span lang="NO-BOK">Perubahan turgor (elastisitas kulit)</span><span></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 28.56%;" valign="top" width="28%">
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NOC </b>:
Tissue Integrity : Skin and Mucous Membranes</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 39.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Integritas
kulit yang baik bisa dipertahankan (sensasi, elastisitas, temperatur,
hidrasi, pigmentasi)</span></div>
<div class="MsoNormal" style="margin-left: 39.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Tidak
ada luka/lesi pada kulit</span></div>
<div class="MsoNormal" style="margin-left: 39.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Perfusi
jaringan baik</span></div>
<div class="MsoNormal" style="margin-left: 39.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Menunjukkan
pemahaman dalam proses perbaikan kulit dan mencegah terjadinya sedera
berulang</span></div>
<div class="MsoNormal" style="margin-left: 39.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Mampu
melindungi kulit dan mempertahankan kelembaban kulit dan perawatan alami</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 35.38%;" valign="top" width="35%">
<div class="MsoNormal">
<span style="font-size: small;"><b>NIC </b>:<b> Pressure Management</b></span></div>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Anjurkan pasien untuk menggunakan pakaian
yang longgar</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Hindari kerutan padaa tempat tidur</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Jaga kebersihan kulit agar tetap bersih dan
kering</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Mobilisasi pasien (ubah posisi pasien)
setiap dua jam sekali</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Monitor kulit akan adanya kemerahan </span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Oleskan lotion atau minyak/baby oil pada
derah yang tertekan </span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Monitor aktivitas dan mobilisasi pasien</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Monitor status nutrisi pasien</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>pasien dengan sabun dan air hangat</span></span></li>
</ul>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
4</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 30.86%;" valign="top" width="30%">
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><span>Kurang
pengetahuan b/d perawatan di rumah dan pembedahan.</span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : </span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Tidak adanya atau kurangnya informasi kognitif sehubungan dengan
topic spesifik.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Batasan karakteristik : memverbalisasikan adanya masalah,
ketidakakuratan mengikuti instruksi, perilaku tidak sesuai.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><span lang="NO-BOK">Faktor yang berhubungan
: keterbatasan kognitif, interpretasi terhadap informasi yang salah,
kurangnya keinginan untuk mencari informasi, tidak mengetahui sumber-sumber
informasi.</span><span></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 28.56%;" valign="top" width="28%">
<div class="MsoNormal">
<span style="font-size: small;"><b>NOC :</b></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.3in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span>Kowlwdge : disease process<span></span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.3in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span>Kowledge : health Behavior<span></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><b>Kriteria
Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Pasien
dan keluarga menyatakan pemahaman tentang penyakit, kondisi, prognosis dan
program pengobatan</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Pasien
dan keluarga mampu melaksanakan prosedur yang dijelaskan secara benar</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Pasien
dan keluarga mampu menjelaskan kembali apa yang dijelaskan perawat/tim
kesehatan lainnya</span></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 35.38%;" valign="top" width="35%">
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>NIC :</b></span></div>
<div class="MsoHeading7" style="line-height: normal;">
<span style="font-size: small;">
Teaching
: disease Process</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Berikan penilaian
tentang tingkat pengetahuan pasien tentang proses penyakit yang spesifik </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Jelaskan patofisiologi
dari penyakit dan bagaimana hal ini berhubungan dengan anatomi dan fisiologi,
dengan cara yang tepat. </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Gambarkan tanda dan
gejala yang biasa muncul pada penyakit, dengan cara yang tepat </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Gambarkan proses
penyakit, dengan cara yang tepat </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">identifikasi kemungkinan
penyebab, dengna cara yang tepat </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Sediakan informasi pada
pasien tentang kondisi, dengan cara yang tepat </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Hindari jaminan yang
kosong </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Sediakan bagi keluarga
atau SO informasi tentang kemajuan pasien dengan cara yang tepat </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Diskusikan perubahan
gaya hidup yang mungkin diperlukan untuk mencegah komplikasi di masa yang
akan datang dan atau proses pengontrolan penyakit </span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Diskusikan pilihan
terapi atau penanganan</span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Dukung pasien untuk
mengeksplorasi atau mendapatkan second opinion dengan cara yang tepat atau
diindikasikan </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Eksplorasi kemungkinan
sumber atau dukungan, dengan cara yang tepat </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Rujuk pasien pada grup atau agensi di komunitas
lokal, dengan cara yang tepat</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Instruksikan pasien mengenai tanda dan gejala untuk
melaporkan pada pemberi</span> <span lang="NO-BOK">perawatan kesehatan, dengan cara yang tepat.</span></span></div>
<div class="MsoNormal" style="margin-left: 3.65pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="margin-left: 3.65pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="margin-left: 3.65pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
5</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 30.86%;" valign="top" width="30%">
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><span>Ketidakseimbangan
nutrisi kurang dari kebutuhan tubuh b/d ketidakmampuan mencerna makanan</span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : Intake nutrisi tidak cukup untuk
keperluan metabolisme tubuh.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Batasan karakteristik : </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Berat badan 20 % atau lebih di bawah ideal </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Dilaporkan adanya intake makanan yang kurang
dari RDA (Recomended Daily Allowance) </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Membran mukosa dan konjungtiva pucat </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kelemahan otot yang digunakan untuk
menelan/mengunyah </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Luka, inflamasi pada rongga mulut </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Mudah merasa kenyang, sesaat setelah
mengunyah makanan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Dilaporkan atau fakta adanya kekurangan
makanan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Dilaporkan adanya perubahan sensasi rasa </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perasaan ketidakmampuan untuk mengunyah
makanan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Miskonsepsi </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kehilangan BB dengan makanan cukup </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Keengganan untuk makan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kram pada abdomen </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Tonus otot jelek </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Nyeri abdominal dengan atau tanpa patologi </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kurang berminat terhadap makanan</span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Pembuluh darah kapiler mulai rapuh </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Diare dan atau steatorrhea </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kehilangan rambut yang cukup banyak (rontok) </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Suara usus hiperaktif</span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Kurangnya informasi, misinformasi</span><span></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Faktor-faktor yang berhubungan : </span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><span lang="NO-BOK">Ketidakmampuan pemasukan atau mencerna makanan atau mengabsorpsi zat-zat
gizi berhubungan dengan faktor biologis, psikologis atau ekonomi.</span><span></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 28.56%;" valign="top" width="28%">
<div class="MsoNormal">
<span style="font-size: small;"><b>NOC :</b></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Nutritional Status : food and
Fluid Intake</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><b>Kriteria
Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Adanya peningkatan berat
badan sesuai dengan tujuan</span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Berat badan ideal sesuai
dengan tinggi badan</span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Mampu mengidentifikasi
kebutuhan nutrisi</span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Tidak ada tanda tanda
malnutrisi</span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Tidak terjadi penurunan berat
badan yang berarti</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 35.38%;" valign="top" width="35%">
<div class="MsoNormal">
<span style="font-size: small;"><b>Nutrition
Management</b></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Kaji adanya alergi makanan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Kolaborasi dengan ahli gizi untuk menentukan jumlah kalori dan nutrisi
yang dibutuhkan pasien.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Anjurkan pasien untuk meningkatkan intake Fe</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Anjurkan pasien untuk meningkatkan protein dan vitamin C</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan substansi gula</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Yakinkan diet yang dimakan mengandung tinggi serat untuk mencegah
konstipasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan makanan yang terpilih ( sudah dikonsultasikan dengan ahli
gizi)</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Ajarkan pasien bagaimana membuat catatan makanan harian.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor jumlah nutrisi dan kandungan kalori</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan informasi tentang kebutuhan nutrisi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Kaji kemampuan pasien untuk mendapatkan nutrisi yang dibutuhkan</span></span></div>
<div class="MsoNormal" style="margin-left: 3.55pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><b>Nutrition
Monitoring</b></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>BB pasien dalam batas normal</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor adanya penurunan berat badan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor tipe dan jumlah aktivitas yang biasa dilakukan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor interaksi anak atau orangtua selama makan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor lingkungan selama makan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Jadwalkan pengobatan<span> </span>dan
tindakan tidak selama jam makan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor kulit kering dan perubahan pigmentasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor turgor kulit</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor kekeringan, rambut kusam, dan mudah patah</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor mual dan muntah</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor kadar albumin, total protein, Hb, dan kadar Ht</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor makanan kesukaan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor pertumbuhan dan perkembangan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor pucat, kemerahan, dan kekeringan jaringan konjungtiva</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor kalori dan intake nuntrisi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Catat adanya edema,
hiperemik, hipertonik papila lidah dan cavitas oral.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Catat jika lidah
berwarna magenta, scarlet</span></span></div>
<div class="MsoNormal" style="margin-left: 3.55pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
6</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 30.86%;" valign="top" width="30%">
<div class="MsoNormal">
<span style="font-size: small;"><span>Resiko infeksi b/d pembedahan</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : Peningkatan resiko masuknya organisme patogen</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Faktor-faktor resiko : </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Prosedur Infasif</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Ketidakcukupan pengetahuan untuk menghindari
paparan patogen </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Trauma </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kerusakan jaringan dan peningkatan paparan
lingkungan </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Ruptur membran amnion</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Agen farmasi (imunosupresan)</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Malnutrisi </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Peningkatan paparan lingkungan patogen </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Imonusupresi </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Ketidakadekuatan imum buatan </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Tidak adekuat pertahanan sekunder (penurunan Hb,
Leukopenia, penekanan respon inflamasi)</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Tidak adekuat pertahanan tubuh primer (kulit tidak
utuh, trauma jaringan, penurunan kerja silia, cairan tubuh statis, perubahan
sekresi pH, perubahan peristaltik)</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Penyakit kronik</span></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 28.56%;" valign="top" width="28%">
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NOC : </b></span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Immune
Status</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Knowledge
: Infection control</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Risk
control</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Klien
bebas dari tanda dan gejala infeksi</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Mendeskripsikan
proses penularan penyakit, factor yang mempengaruhi penularan serta
penatalaksanaannya,</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Menunjukkan
kemampuan untuk mencegah timbulnya infeksi</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Jumlah
leukosit dalam batas normal</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Menunjukkan
perilaku hidup sehat</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 35.38%;" valign="top" width="35%">
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NIC :</b></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Infection Control (Kontrol infeksi)</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Bersihkan lingkungan setelah dipakai pasien lain</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Pertahankan teknik isolasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Batasi pengunjung bila perlu</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Instruksikan pada pengunjung untuk mencuci tangan saat
berkunjung dan setelah berkunjung meninggalkan pasien</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Gunakan sabun antimikrobia untuk cuci tangan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Cuci tangan setiap sebelum dan sesudah tindakan
kperawtan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Gunakan baju, sarung tangan sebagai alat pelindung</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Pertahankan lingkungan aseptik selama pemasangan alat</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Ganti letak IV perifer dan line central dan dressing
sesuai dengan petunjuk umum</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Gunakan kateter intermiten untuk menurunkan infeksi
kandung kencing </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Tingktkan intake nutrisi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Berikan terapi antibiotik bila perlu</span></span></div>
<div class="MsoNormal" style="margin-left: 3.65pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Infection Protection (proteksi terhadap infeksi)</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Monitor tanda dan gejala infeksi sistemik dan lokal</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Monitor hitung granulosit, WBC</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Monitor kerentanan terhadap infeksi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Batasi pengunjung</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Saring pengunjung terhadap penyakit menular</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Partahankan teknik aspesis pada pasien yang beresiko</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Pertahankan teknik isolasi k/p</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Berikan perawatan kuliat pada area epidema</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Inspeksi kulit dan membran mukosa terhadap kemerahan,
panas, drainase</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Ispeksi kondisi luka / insisi bedah</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Dorong masukkan nutrisi yang cukup</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Dorong masukan cairan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Dorong istirahat</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Instruksikan pasien untuk minum antibiotik sesuai resep</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Ajarkan pasien dan keluarga tanda dan gejala infeksi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Ajarkan cara menghindari infeksi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Laporkan kecurigaan infeksi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Laporkan kultur positif</span><span></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
7</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 30.86%;" valign="top" width="30%">
<div class="MsoBodyText3">
<span style="font-size: small;">
Resiko defisit volume cairan b/d
pengurangan intake cairan</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : Penurunan cairan intravaskuler,
interstisial, dan/atau intrasellular. Ini mengarah ke dehidrasi, kehilangan
cairan dengan pengeluaran sodium</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span>Batasan
Karakteristik : </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Kelemahan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Haus </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Penurunan turgor kulit/lidah </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Membran mukosa/kulit kering </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Peningkatan denyut nadi, penurunan tekanan
darah, penurunan volume/tekanan nadi </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Pengisian vena menurun </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perubahan status mental</span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Konsentrasi urine meningkat </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Temperatur tubuh meningkat </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Hematokrit meninggi </span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Kehilangan berat badan seketika (kecuali pada third spacing)</span><span></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Faktor-faktor yang berhubungan: </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Kehilangan volume cairan secara aktif </span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Kegagalan mekanisme pengaturan</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 28.56%;" valign="top" width="28%">
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NOC: </b></span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Fluid
balance</span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Hydration</span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Nutritional
Status : Food and Fluid Intake</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Mempertahankan
urine output sesuai dengan usia dan BB, BJ urine normal, HT normal</span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Tekanan
darah, nadi, suhu tubuh dalam batas normal</span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Tidak
ada tanda tanda dehidrasi, Elastisitas turgor kulit baik, membran mukosa
lembab, tidak ada rasa haus yang berlebihan</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 35.38%;" valign="top" width="35%">
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoHeading9">
<span style="font-size: small;">
Fluid management</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Timbang popok/pembalut jika diperlukan </span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Pertahankan catatan intake dan output yang akurat</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Monitor status hidrasi ( kelembaban membran mukosa,
nadi adekuat, tekanan darah ortostatik ), jika diperlukan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Monitor vital sign</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Monitor masukan makanan / cairan dan hitung intake
kalori harian</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Kolaborasi pemberian cairan<span> </span>IV </span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Monitor status nutrisi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Kolaborasikan pemberian cairan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Berikan cairan IV pada suhu ruangan </span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Dorong masukan oral</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Berikan penggantian nesogatrik sesuai output</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Dorong keluarga untuk membantu pasien makan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Tawarkan snack ( jus
buah, buah segar )</span><span lang="NL"></span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Kolaborasi dokter jika tanda cairan berlebih muncul
meburuk </span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Atur kemungkinan tranfusi</span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Persiapan untuk tranfusi</span></span></div>
<div class="MsoNormal">
</div>
</td></tr>
</tbody></table>
ERFANSYAH. HRhttp://www.blogger.com/profile/07497970584312798191noreply@blogger.com0tag:blogger.com,1999:blog-2228299828902052163.post-9254948668527240172012-11-21T05:43:00.003-08:002013-03-11T10:03:24.352-07:00Asuhan Keperawatan Morbili Aplikasi NIC, NOC, NANDA<h3 class="post-title entry-title" itemprop="name" style="font-family: "Courier New",Courier,monospace;">
<span style="font-size: small;">
Asuhan Keperawatan Morbili Aplikasi NIC, NOC, NANDA
</span></h3>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span><span style="font-family: "Courier New",Courier,monospace;">
</span><span style="font-family: "Courier New",Courier,monospace; line-height: 150%;"> </span><span style="font-family: "Courier New",Courier,monospace;">
</span></span>
<div class="MsoHeading9" style="font-family: "Courier New",Courier,monospace; line-height: 150%;">
<span style="font-size: small;">
A. <span style="line-height: 150%;">Masalah yang lazim muncul pada klien</span></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>1.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="line-height: 150%;">Resiko penyebaran infeksi b/d organisme purulen</span></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>2.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="line-height: 150%;">Bersihan jalan nafas tidak efektif b/d penumpukan secret</span></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>3.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="line-height: 150%;">Kerusakan integritas kulit b/d penurunan imunitas</span></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>4.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="line-height: 150%;">Ketidakseimbangan nutrisi kurang dari kebutuhan tubuh b/d
intake tidak adekuat</span></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>5.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="line-height: 150%;">Kurang pengetahuan b/d kurangnya informasi</span></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><b><i><span>6.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></i></b><span style="line-height: 150%;">Nyeri
akut b/d agen injury</span></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; line-height: 150%; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><h1 style="font-family: "Courier New",Courier,monospace; line-height: 150%;">
<span style="font-size: small;">
B. Discharge Planning</span></h1>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoBodyText2" style="font-family: "Courier New",Courier,monospace; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>1.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span>Jelaskan
terapi yang diberikan : dosis, efek samping.</span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoBodyText2" style="font-family: "Courier New",Courier,monospace; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>2.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span>Anjurkan
orang tua untukmelengkapi imunisasi jika belum lengkap</span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoBodyText2" style="font-family: "Courier New",Courier,monospace; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>3.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span>Menekankan
pentingnya kontrol ulang sesuai jadwalInformasikan jika terjadi tanda tanda
kekambuhan (demam, batuk)</span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoBodyText2" style="font-family: "Courier New",Courier,monospace; line-height: 150%;">
<span style="font-size: small;"><br /></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span>
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: medium none; font-family: "Courier New",Courier,monospace; width: 100%;"><tbody>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 3.5%;" valign="top" width="3%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>No</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 31.44%;" valign="top" width="31%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>Diagnosa
keperawatan</span></span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 26.58%;" valign="top" width="26%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>Tujuan
dan Kriteria Hasil</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 38.48%;" valign="top" width="38%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>Intervensi</span></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 3.5%;" valign="top" width="3%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
1</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 31.44%;" valign="top" width="31%">
<div class="MsoNormal">
<span style="font-size: small;"><span>Resiko penyebaran infeksi b/d organisme
purulen</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : Peningkatan resiko masuknya organisme patogen</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Faktor-faktor resiko : </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Prosedur Infasif</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Ketidakcukupan pengetahuan untuk menghindari
paparan patogen </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Trauma </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kerusakan jaringan dan peningkatan paparan
lingkungan </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Ruptur membran amnion</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Agen farmasi (imunosupresan)</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Malnutrisi </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Peningkatan paparan lingkungan patogen </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Imonusupresi </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Ketidakadekuatan imum buatan </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Tidak adekuat pertahanan sekunder (penurunan Hb,
Leukopenia, penekanan respon inflamasi)</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Tidak adekuat pertahanan tubuh primer (kulit tidak
utuh, trauma jaringan, penurunan kerja silia, cairan tubuh statis, perubahan
sekresi pH, perubahan peristaltik)</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Penyakit kronik</span></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 26.58%;" valign="top" width="26%">
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NOC : </b></span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Immune
Status</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Knowledge
: Infection control</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Risk
control</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Klien
bebas dari tanda dan gejala infeksi</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Mendeskripsikan
proses penularan penyakit, factor yang mempengaruhi penularan serta penatalaksanaannya,</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Menunjukkan
kemampuan untuk mencegah timbulnya infeksi</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Jumlah
leukosit dalam batas normal</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Menunjukkan
perilaku hidup sehat</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 38.48%;" valign="top" width="38%">
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NIC :</b></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Infection Control (Kontrol infeksi)</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Bersihkan lingkungan setelah dipakai pasien lain</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Pertahankan teknik isolasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Batasi pengunjung bila perlu</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Instruksikan pada pengunjung untuk mencuci tangan saat
berkunjung dan setelah berkunjung meninggalkan pasien</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Gunakan sabun antimikrobia untuk cuci tangan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Cuci tangan setiap sebelum dan sesudah tindakan
kperawtan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Gunakan baju, sarung tangan sebagai alat pelindung</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Pertahankan lingkungan aseptik selama pemasangan alat</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Ganti letak IV perifer dan line central dan dressing
sesuai dengan petunjuk umum</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Gunakan kateter intermiten untuk menurunkan infeksi
kandung kencing </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Tingktkan intake nutrisi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Berikan terapi antibiotik bila perlu</span></span></div>
<div class="MsoNormal" style="margin-left: 3.65pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Infection Protection (proteksi terhadap infeksi)</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Monitor tanda dan gejala infeksi sistemik dan lokal</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Monitor hitung granulosit, WBC</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Monitor kerentanan terhadap infeksi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Batasi pengunjung</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Saring pengunjung terhadap penyakit menular</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Partahankan teknik aspesis pada pasien yang beresiko</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Pertahankan teknik isolasi k/p</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Berikan perawatan kuliat pada area epidema</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Inspeksi kulit dan membran mukosa terhadap kemerahan,
panas, drainase</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Ispeksi kondisi luka / insisi bedah</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Dorong masukkan nutrisi yang cukup</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Dorong masukan cairan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Dorong istirahat</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Instruksikan pasien untuk minum antibiotik sesuai resep</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Ajarkan pasien dan keluarga tanda dan gejala infeksi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Ajarkan cara menghindari infeksi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Laporkan kecurigaan infeksi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Laporkan kultur positif</span></span></div>
<div class="MsoNormal" style="margin-left: 3.65pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 3.5%;" valign="top" width="3%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
2</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 31.44%;" valign="top" width="31%">
<div class="MsoNormal">
<span style="font-size: small;"><span>Bersihan jalan nafas tidak efektif b/d
penumpukan secret.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : Ketidakmampuan untuk membersihkan
sekresi atau obstruksi dari saluran pernafasan untuk mempertahankan
kebersihan jalan nafas.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span style="font-size: small;"><span lang="NO-BOK" style="line-height: 150%;">Batasan Karakteristik :</span></span></div>
<div class="MsoNormal" style="margin-left: 23.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Dispneu, Penurunan suara nafas</span></span></div>
<div class="MsoNormal" style="margin-left: 23.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Orthopneu</span></span></div>
<div class="MsoNormal" style="margin-left: 23.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Cyanosis</span></span></div>
<div class="MsoNormal" style="margin-left: 23.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kelainan suara nafas (rales, wheezing)</span></span></div>
<div class="MsoNormal" style="margin-left: 23.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kesulitan berbicara</span></span></div>
<div class="MsoNormal" style="margin-left: 23.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Batuk, tidak efekotif atau tidak ada</span></span></div>
<div class="MsoNormal" style="margin-left: 23.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Mata melebar</span></span></div>
<div class="MsoNormal" style="margin-left: 23.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Produksi sputum</span></span></div>
<div class="MsoNormal" style="margin-left: 23.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Gelisah</span></span></div>
<div class="MsoNormal" style="margin-left: 23.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perubahan frekuensi dan irama nafas</span></span></div>
<div class="MsoNormal" style="margin-left: 5.05pt;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span style="font-size: small;"><span lang="NO-BOK" style="line-height: 150%;">Faktor-faktor yang berhubungan: </span></span></div>
<div class="MsoNormal" style="margin-left: 23.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Lingkungan : merokok, menghirup asap rokok,
perokok pasif-POK, infeksi</span></span></div>
<div class="MsoNormal" style="margin-left: 23.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Fisiologis : disfungsi neuromuskular,
hiperplasia dinding bronkus, alergi jalan nafas, asma.</span></span></div>
<div class="MsoNormal" style="margin-left: 23.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Obstruksi jalan nafas : spasme jalan nafas,
sekresi tertahan, banyaknya mukus, adanya jalan nafas buatan, sekresi
bronkus, adanya eksudat di alveolus, adanya benda asing di jalan nafas.</span><span lang="NO-BOK"></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 26.58%;" valign="top" width="26%">
<div class="MsoNormal">
<span style="font-size: small;"><span>NOC : </span></span></div>
<div class="MsoNormal" style="margin-left: 26.45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Respiratory
status : Ventilation</span></span></div>
<div class="MsoNormal" style="margin-left: 26.45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Respiratory
status : Airway patency</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;">
Kriteria
Hasil :</span></div>
<div class="MsoNormal" style="margin-left: 21.5pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Mendemonstrasikan batuk efektif dan suara nafas
yang bersih, tidak ada sianosis dan dyspneu (mampu bernafas dengan mudah,
tidak ada pursed lips)</span></span></div>
<div class="MsoNormal" style="margin-left: 21.5pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Menunjukkan
jalan nafas yang paten</span><span> (</span><span>klien tidak merasa tercekik, irama nafas,
frekuensi pernafasan dalam rentang normal, tidak ada suara nafas abnormal)</span></span></div>
<div class="MsoNormal" style="margin-left: 21.5pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Mampu
mengidentifikasikan dan mencegah factor yang dapat menghambat jalan nafas</span></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 38.48%;" valign="top" width="38%">
<div class="MsoNormal">
<span style="font-size: small;"><b>NIC :</b></span></div>
<div class="MsoHeading7" style="line-height: normal;">
<span style="font-size: small;">
Airway suction</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Pastikan kebutuhan oral / tracheal suctioning</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span><span> </span>Auskultasi suara nafas sebelum
dan sesudah suctioning.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Informasikan pada klien dan keluarga tentang suctioning</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Minta klien nafas dalam sebelum suction dilakukan.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan O2 dengan menggunakan nasal untuk memfasilitasi suksion
nasotrakeal</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Gunakan alat yang steril sitiap melakukan tindakan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Anjurkan pasien untuk istirahat dan napas dalam setelah kateter
dikeluarkan dari nasotrakeal</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor status oksigen pasien</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Ajarkan keluarga bagaimana cara melakukan suksion</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Hentikan suksion dan
berikan oksigen apabila pasien menunjukkan bradikardi, peningkatan saturasi
O2, dll.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoHeading7" style="line-height: normal;">
<span style="font-size: small;">
Airway Management</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Buka jalan nafas, guanakan teknik chin lift atau jaw
thrust bila perlu</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Posisikan pasien untuk memaksimalkan ventilasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Identifikasi pasien perlunya pemasangan alat jalan
nafas buatan </span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Pasang mayo bila perlu</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Lakukan fisioterapi dada jika perlu</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Keluarkan sekret dengan batuk atau suction</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Auskultasi suara nafas, catat adanya suara tambahan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Lakukan suction pada mayo</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Kolaborasi pemberian bronkodilator bila perlu</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Berikan pelembab udara Kassa basah NaCl Lembab</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="FR">Atur intake untuk cairan mengoptimalkan keseimbangan.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="FR">Monitor respirasi dan status O2</span></span></div>
<div class="MsoNormal" style="margin-left: 3.55pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 3.5%;" valign="top" width="3%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
3</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 31.44%;" valign="top" width="31%">
<div class="MsoNormal">
<span style="font-size: small;"><span>Kerusakan integritas kulit b/d penurunan
imunitas</span></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 26.58%;" valign="top" width="26%">
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NOC </b>:
Tissue Integrity : Skin and Mucous Membranes</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 39.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Integritas
kulit yang baik bisa dipertahankan (sensasi, elastisitas, temperatur,
hidrasi, pigmentasi)</span></div>
<div class="MsoNormal" style="margin-left: 39.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Tidak
ada luka/lesi pada kulit</span></div>
<div class="MsoNormal" style="margin-left: 39.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Perfusi
jaringan baik</span></div>
<div class="MsoNormal" style="margin-left: 39.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Menunjukkan
pemahaman dalam proses perbaikan kulit dan mencegah terjadinya sedera
berulang</span></div>
<div class="MsoNormal" style="margin-left: 39.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Mampu
melindungi kulit dan mempertahankan kelembaban kulit dan perawatan alami</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 38.48%;" valign="top" width="38%">
<div class="MsoNormal">
<span style="font-size: small;"><b>NIC </b>:<b> Pressure Management</b></span></div>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Anjurkan pasien untuk menggunakan pakaian
yang longgar</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Hindari kerutan padaa tempat tidur</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Jaga kebersihan kulit agar tetap bersih dan
kering</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Mobilisasi pasien (ubah posisi pasien)
setiap dua jam sekali</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Monitor kulit akan adanya kemerahan </span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Oleskan lotion atau minyak/baby oil pada
derah yang tertekan </span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Monitor aktivitas dan mobilisasi pasien</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Monitor status nutrisi pasien</span></span></li>
</ul>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 3.5%;" valign="top" width="3%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
4</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 31.44%;" valign="top" width="31%">
<div class="MsoNormal">
<span style="font-size: small;"><span>Ketidakseimbangan nutrisi kurang dari
kebutuhan tubuh b/d intake tidak adekuat</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : Intake nutrisi tidak cukup untuk
keperluan metabolisme tubuh.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Batasan karakteristik : </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Berat badan 20 % atau lebih di bawah ideal </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Dilaporkan adanya intake makanan yang kurang
dari RDA (Recomended Daily Allowance) </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Membran mukosa dan konjungtiva pucat </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kelemahan otot yang digunakan untuk
menelan/mengunyah </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Luka, inflamasi pada rongga mulut </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Mudah merasa kenyang, sesaat setelah
mengunyah makanan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Dilaporkan atau fakta adanya kekurangan
makanan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Dilaporkan adanya perubahan sensasi rasa </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perasaan ketidakmampuan untuk mengunyah
makanan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Miskonsepsi </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kehilangan BB dengan makanan cukup </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Keengganan untuk makan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kram pada abdomen </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Tonus otot jelek </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Nyeri abdominal dengan atau tanpa patologi </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kurang berminat terhadap makanan</span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Pembuluh darah kapiler mulai rapuh </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Diare dan atau steatorrhea </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kehilangan rambut yang cukup banyak (rontok) </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Suara usus hiperaktif</span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Kurangnya informasi, misinformasi</span><span></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Faktor-faktor yang berhubungan : </span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Ketidakmampuan pemasukan atau mencerna makanan atau
mengabsorpsi zat-zat gizi berhubungan dengan faktor biologis, psikologis atau
ekonomi.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 26.58%;" valign="top" width="26%">
<div class="MsoNormal">
<span style="font-size: small;"><b>NOC :</b></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Nutritional Status : food and
Fluid Intake</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><b>Kriteria
Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Adanya peningkatan berat
badan sesuai dengan tujuan</span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Berat badan ideal sesuai
dengan tinggi badan</span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Mampu mengidentifikasi
kebutuhan nutrisi</span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Tidak ada tanda tanda
malnutrisi</span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Tidak terjadi penurunan berat
badan yang berarti</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 38.48%;" valign="top" width="38%">
<div class="MsoNormal">
<span style="font-size: small;"><b>Nutrition
Management</b></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Kaji adanya alergi makanan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Kolaborasi dengan ahli gizi untuk menentukan jumlah kalori dan nutrisi
yang dibutuhkan pasien.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Anjurkan pasien untuk meningkatkan intake Fe</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Anjurkan pasien untuk meningkatkan protein dan vitamin C</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan substansi gula</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Yakinkan diet yang dimakan mengandung tinggi serat untuk mencegah
konstipasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan makanan yang terpilih ( sudah dikonsultasikan dengan ahli
gizi)</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Ajarkan pasien bagaimana membuat catatan makanan harian.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor jumlah nutrisi dan kandungan kalori</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan informasi tentang kebutuhan nutrisi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Kaji kemampuan pasien untuk mendapatkan nutrisi yang dibutuhkan</span></span></div>
<div class="MsoNormal" style="margin-left: 3.55pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><b>Nutrition
Monitoring</b></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>BB pasien dalam batas normal</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor adanya penurunan berat badan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor tipe dan jumlah aktivitas yang biasa dilakukan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor interaksi anak atau orangtua selama makan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor lingkungan selama makan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Jadwalkan pengobatan<span> </span>dan
tindakan tidak selama jam makan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor kulit kering dan perubahan pigmentasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor turgor kulit</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor kekeringan, rambut kusam, dan mudah patah</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor mual dan muntah</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor kadar albumin, total protein, Hb, dan kadar Ht</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor makanan kesukaan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor pertumbuhan dan perkembangan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor pucat, kemerahan, dan kekeringan jaringan konjungtiva</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor kalori dan intake nuntrisi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Catat adanya edema,
hiperemik, hipertonik papila lidah dan cavitas oral.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Catat jika lidah
berwarna magenta, scarlet</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 3.5%;" valign="top" width="3%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
5</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 31.44%;" valign="top" width="31%">
<div class="MsoNormal">
<span style="font-size: small;"><span>Kurang pengetahuan b/d kurangnya informasi</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : </span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Tidak adanya atau kurangnya informasi kognitif sehubungan dengan
topic spesifik.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Batasan karakteristik : memverbalisasikan adanya masalah,
ketidakakuratan mengikuti instruksi, perilaku tidak sesuai.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Faktor yang berhubungan : keterbatasan kognitif, interpretasi
terhadap informasi yang salah, kurangnya keinginan untuk mencari informasi,
tidak mengetahui sumber-sumber informasi.</span></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 26.58%;" valign="top" width="26%">
<div class="MsoNormal">
<span style="font-size: small;"><b>NOC :</b></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.3in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span>Kowlwdge : disease process<span></span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.3in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span>Kowledge : health Behavior<span></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><b>Kriteria
Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Pasien
dan keluarga menyatakan pemahaman tentang penyakit, kondisi, prognosis dan
program pengobatan</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Pasien
dan keluarga mampu melaksanakan prosedur yang dijelaskan secara benar</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Pasien
dan keluarga mampu menjelaskan kembali apa yang dijelaskan perawat/tim
kesehatan lainnya</span></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 38.48%;" valign="top" width="38%">
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>NIC :</b></span></div>
<div class="MsoHeading7" style="line-height: normal;">
<span style="font-size: small;">
Teaching
: disease Process</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Berikan penilaian
tentang tingkat pengetahuan pasien tentang proses penyakit yang spesifik </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Jelaskan patofisiologi
dari penyakit dan bagaimana hal ini berhubungan dengan anatomi dan fisiologi,
dengan cara yang tepat. </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Gambarkan tanda dan
gejala yang biasa muncul pada penyakit, dengan cara yang tepat </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Gambarkan proses
penyakit, dengan cara yang tepat </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Identifikasi kemungkinan
penyebab, dengna cara yang tepat </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Sediakan informasi pada
pasien tentang kondisi, dengan cara yang tepat </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Hindari harapan yang
kosong </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Sediakan bagi keluarga
atau SO informasi tentang kemajuan pasien dengan cara yang tepat </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Diskusikan perubahan
gaya hidup yang mungkin diperlukan untuk mencegah komplikasi di masa yang
akan datang dan atau proses pengontrolan penyakit </span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Diskusikan pilihan
terapi atau penanganan</span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Dukung pasien untuk
mengeksplorasi atau mendapatkan second opinion dengan cara yang tepat atau
diindikasikan </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Eksplorasi kemungkinan sumber atau dukungan, dengan
cara yang tepat </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Instruksikan pasien mengenai tanda dan gejala untuk
melaporkan pada pemberi</span> <span lang="NO-BOK">perawatan kesehatan, dengan cara yang tepat</span></span></div>
<div class="MsoNormal" style="margin-left: 3.65pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="margin-left: 3.65pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="margin-left: 3.65pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="margin-left: 3.65pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="margin-left: 3.65pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="margin-left: 3.65pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="margin-left: 3.65pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 3.5%;" valign="top" width="3%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
6</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 31.44%;" valign="top" width="31%">
<div class="MsoNormal">
<span style="font-size: small;"><span>Nyeri akut b/d agen injury</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : </span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Sensori yang tidak menyenangkan dan pengalaman
emosional yang muncul secara aktual atau potensial kerusakan jaringan atau
menggambarkan adanya kerusakan (Asosiasi Studi Nyeri Internasional): serangan
mendadak atau pelan intensitasnya dari ringan sampai berat yang dapat
diantisipasi dengan akhir yang dapat diprediksi dan dengan durasi kurang dari
6 bulan.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Batasan karakteristik : </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Laporan secara verbal atau non verbal </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Fakta dari observasi </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Posisi antalgic untuk menghindari nyeri </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Gerakan melindungi </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Tingkah laku berhati-hati</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Muka topeng </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Gangguan tidur (mata sayu, tampak capek,
sulit atau gerakan kacau, menyeringai)</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Terfokus pada diri sendiri </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Fokus menyempit (penurunan persepsi waktu,
kerusakan proses berpikir, penurunan interaksi dengan orang dan lingkungan) </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Tingkah laku distraksi, contoh : jalan-jalan,
menemui orang lain dan/atau aktivitas, aktivitas berulang-ulang)</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Respon autonom (seperti diaphoresis,
perubahan tekanan darah, perubahan nafas, nadi dan dilatasi pupil)</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perubahan autonomic dalam tonus otot (mungkin
dalam rentang dari lemah ke kaku) </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Tingkah laku ekspresif (contoh : gelisah,
merintih, menangis, waspada, iritabel, nafas panjang/berkeluh kesah) </span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perubahan dalam nafsu makan dan minum</span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 2.1pt;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Faktor yang berhubungan : </span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Agen injuri (biologi, kimia, fisik, psikologis)</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 26.58%;" valign="top" width="26%">
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NOC : </b></span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Pain
Level,</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Pain
control,</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Comfort
level</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Mampu
mengontrol nyeri (tahu penyebab nyeri, mampu menggunakan tehnik
nonfarmakologi untuk mengurangi nyeri, mencari bantuan)</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Melaporkan
bahwa nyeri berkurang dengan menggunakan manajemen nyeri</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Mampu
mengenali nyeri (skala, intensitas, frekuensi dan tanda nyeri)</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Menyatakan
rasa nyaman setelah nyeri berkurang</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 38.48%;" valign="top" width="38%">
<h1>
<span style="font-size: small;">
Pain Management</span></h1>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Lakukan pengkajian nyeri secara komprehensif termasuk lokasi,
karakteristik, durasi, frekuensi, kualitas dan faktor presipitasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Observasi reaksi nonverbal dari ketidaknyamanan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Gunakan teknik komunikasi terapeutik untuk mengetahui pengalaman nyeri
pasien</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Kaji kultur yang mempengaruhi respon nyeri</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Evaluasi pengalaman nyeri masa lampau</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Evaluasi bersama pasien dan tim kesehatan lain tentang ketidakefektifan
kontrol nyeri masa lampau</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Bantu pasien dan keluarga untuk mencari dan menemukan dukungan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Kontrol lingkungan yang dapat mempengaruhi nyeri seperti suhu ruangan,
pencahayaan dan kebisingan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Kurangi faktor presipitasi nyeri</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Pilih dan lakukan penanganan nyeri (farmakologi, non farmakologi dan
inter personal)</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Kaji tipe dan sumber nyeri untuk menentukan intervensi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Ajarkan tentang teknik non farmakologi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan analgetik untuk mengurangi nyeri</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Evaluasi keefektifan kontrol nyeri</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Tingkatkan istirahat</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Kolaborasikan dengan dokter jika ada keluhan dan tindakan nyeri tidak
berhasil</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Monitor penerimaan pasien tentang manajemen nyeri</span></span></div>
<div class="MsoNormal" style="margin-left: 3.55pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Analgesic Administration</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Tentukan lokasi, karakteristik, kualitas, dan derajat nyeri sebelum
pemberian obat</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Cek instruksi dokter tentang jenis obat, dosis, dan frekuensi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Cek riwayat alergi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Pilih analgesik yang diperlukan atau kombinasi dari analgesik ketika
pemberian lebih dari satu </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Tentukan pilihan analgesik tergantung tipe dan beratnya nyeri</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Tentukan analgesik pilihan, rute pemberian, dan dosis optimal</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Pilih rute pemberian secara IV, IM untuk pengobatan nyeri secara
teratur</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor vital sign sebelum dan sesudah pemberian analgesik pertama
kali</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Berikan analgesik
tepat waktu terutama saat nyeri hebat</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Evaluasi efektivitas
analgesik, tanda dan gejala (efek samping)</span></span></div>
</td></tr>
</tbody></table>
ERFANSYAH. HRhttp://www.blogger.com/profile/07497970584312798191noreply@blogger.com0tag:blogger.com,1999:blog-2228299828902052163.post-33472936140893981782012-11-21T05:42:00.003-08:002013-03-11T10:03:24.313-07:00Asuhan Keperawatan Idiopatik Trombo Purpura (ITP) Aplikasi NIC, NOC, NANDA<h3 class="post-title entry-title" itemprop="name" style="font-family: Georgia,"Times New Roman",serif;">
<span style="font-size: small;">
Asuhan Keperawatan Idiopatik Trombo Purpura (ITP) Aplikasi NIC, NOC, NANDA </span></h3>
<h3 class="post-title entry-title" itemprop="name" style="font-family: Georgia,"Times New Roman",serif;">
<span style="font-size: small;"> </span></h3>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span><span style="font-family: Georgia,"Times New Roman",serif;">
</span><b style="font-family: Georgia,"Times New Roman",serif;"><span style="line-height: 150%;"></span></b></span>
<h3 style="font-family: Georgia,"Times New Roman",serif;">
<span style="font-size: small;"><span><span>A.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span>Masalah
Yang lazim muncul pada klien</span></h3>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>1.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="line-height: 150%;">Resiko Injury b/d kecenderungan perdarahan sekunder</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>1.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="line-height: 150%;">Resiko infeksi b/d imunosupresi</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>2.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span style="line-height: 150%;">Resiko
ketidakseimbangan nutrisi lebih dari kebutuhan tubuh b/d peningkatan</span><span style="line-height: 150%;"> </span><span style="line-height: 150%;">nafsu makan.</span><span style="line-height: 150%;"></span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;"><b><span>3.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></b><span style="line-height: 150%;">PK : Anemia</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoFooter" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%;">
<span style="font-size: small;"><br /></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><h3 style="font-family: Georgia,"Times New Roman",serif;">
<span style="font-size: small;"><span><span>B.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span>Discharge
Planning</span></h3>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>1.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span style="line-height: 150%;">Berikan pada orang tua dan anak instruksi instruksi pemberian obat</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 1in; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>a.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span style="line-height: 150%;">waktu dan rute pemberian</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 1in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>b.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span style="line-height: 150%;">pemantauan adanya efek yang tidak diinginkan</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>2.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span style="line-height: 150%;">Instruksikan pada orang tua dan anak untuk memantau adanya tanda tanda
dan gejala trombositopenia dan melaporkannya dengan segera missal petekia,
ekimosis, darah dalam urine atau feses dan sakit kepala</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>3.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span style="line-height: 150%;">Minta orang tua untuk memantau aktivitas anak</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 1in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>a.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span style="line-height: 150%;">anjurkan aktivita yang tenang, anak tidak boleh mengikuti olahraga
kontak fisik sampai jumlah trombositnya normal</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 1in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>b.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span style="line-height: 150%;">seimbangkan waktu istirahat dan aktivitas, tingkatkan aktivitas sesuai
toleransi</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 1in; text-indent: -0.25in;">
<span style="font-size: small;"><span>c.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="line-height: 150%;">Instruksikan orang tua untuk menghindari kontak anak dengan orang yang
sedang terinfeksi terutama ISPA</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 1in;">
<span style="font-size: small;"><br /></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span>
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: medium none; font-family: Georgia,"Times New Roman",serif; width: 100%;"><tbody>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 3.5%;" valign="top" width="3%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>No</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 31.44%;" valign="top" width="31%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>Diagnosa
keperawatan</span></span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 29.12%;" valign="top" width="29%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>Tujuan
dan Kriteria Hasil</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 35.94%;" valign="top" width="35%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>Intervensi</span></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 3.5%;" valign="top" width="3%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
1</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 31.44%;" valign="top" width="31%">
<div class="MsoNormal">
<span style="font-size: small;"><span>Resiko Injury b/d kecenderungan perdarahan
sekunder</span></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 29.12%;" valign="top" width="29%">
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NOC</b>
: Risk Kontrol</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 20.75pt; text-align: justify; text-indent: -11.75pt;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Klien
terbebas dari cedera</span></div>
<div class="MsoNormal" style="margin-left: 20.75pt; text-align: justify; text-indent: -11.75pt;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Klien
mampu menjelaskan cara/metode untukmencegah injury/cedera</span></div>
<div class="MsoNormal" style="margin-left: 20.75pt; text-align: justify; text-indent: -11.75pt;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Klien
mampu menjelaskan factor resiko dari lingkungan/perilaku personal</span></div>
<div class="MsoNormal" style="margin-left: 20.75pt; text-align: justify; text-indent: -11.75pt;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Mampumemodifikasi
gaya hidup untukmencegah injury</span></div>
<div class="MsoNormal" style="margin-left: 20.75pt; text-align: justify; text-indent: -11.75pt;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Menggunakan
fasilitas kesehatan yang ada</span></div>
<div class="MsoNormal" style="margin-left: 20.75pt; text-align: justify; text-indent: -11.75pt;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Mampu
mengenali perubahan status kesehatan</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 35.94%;" valign="top" width="35%">
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NIC</b>
: <b>Environment Management (Manajemen lingkungan)</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Sediakan lingkungan yang aman untuk pasien</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Identifikasi kebutuhan keamanan pasien, sesuai dengan kondisi fisik
dan fungsi kognitif<span> </span>pasien dan riwayat
penyakit terdahulu pasien</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Menghindarkan lingkungan yang berbahaya (misalnya memindahkan
perabotan)</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Memasang side rail tempat tidur</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Menyediakan tempat tidur yang nyaman dan bersih</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Menempatkan saklar lampu ditempat yang mudah dijangkau pasien.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Membatasi pengunjung</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Memberikan penerangan yang cukup</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Menganjurkan keluarga untuk menemani pasien.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Mengontrol lingkungan dari kebisingan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Memindahkan barang-barang yang dapat membahayakan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan penjelasan pada pasien dan keluarga atau pengunjung adanya
perubahan status kesehatan dan penyebab penyakit.</span><span></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 3.5%;" valign="top" width="3%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
2</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 31.44%;" valign="top" width="31%">
<div class="MsoNormal">
<span style="font-size: small;"><span>Resiko infeksi b/d imunosupresi</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : Peningkatan resiko masuknya organisme patogen</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Faktor-faktor resiko : </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Prosedur Infasif</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Ketidakcukupan pengetahuan untuk menghindari
paparan patogen </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Trauma </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kerusakan jaringan dan peningkatan paparan
lingkungan </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Ruptur membran amnion</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Agen farmasi (imunosupresan)</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Malnutrisi </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Peningkatan paparan lingkungan patogen </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Imonusupresi </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Ketidakadekuatan imum buatan </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Tidak adekuat pertahanan sekunder (penurunan Hb,
Leukopenia, penekanan respon inflamasi)</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Tidak adekuat pertahanan tubuh primer (kulit tidak
utuh, trauma jaringan, penurunan kerja silia, cairan tubuh statis, perubahan
sekresi pH, perubahan peristaltik)</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Penyakit kronik</span></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 29.12%;" valign="top" width="29%">
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NOC : </b></span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Immune
Status</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Knowledge
: Infection control</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Risk
control</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Klien
bebas dari tanda dan gejala infeksi</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Mendeskripsikan
proses penularan penyakit, factor yang mempengaruhi penularan serta
penatalaksanaannya,</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Menunjukkan
kemampuan untuk mencegah timbulnya infeksi</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Jumlah
leukosit dalam batas normal</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Menunjukkan
perilaku hidup sehat</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 35.94%;" valign="top" width="35%">
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NIC :</b></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Infection Control (Kontrol infeksi)</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Bersihkan lingkungan setelah dipakai pasien lain</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Pertahankan teknik isolasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Batasi pengunjung bila perlu</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Instruksikan pada pengunjung untuk mencuci tangan saat
berkunjung dan setelah berkunjung meninggalkan pasien</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Gunakan sabun antimikrobia untuk cuci tangan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Cuci tangan setiap sebelum dan sesudah tindakan
kperawtan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Gunakan baju, sarung tangan sebagai alat pelindung</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Pertahankan lingkungan aseptik selama pemasangan alat</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Ganti letak IV perifer dan line central dan dressing
sesuai dengan petunjuk umum</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Gunakan kateter intermiten untuk menurunkan infeksi
kandung kencing </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Tingktkan intake nutrisi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Berikan terapi antibiotik bila perlu</span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Infection Protection (proteksi terhadap infeksi)</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Monitor tanda dan gejala infeksi sistemik dan lokal</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Monitor hitung granulosit, WBC</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Monitor kerentanan terhadap infeksi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Batasi pengunjung</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Saring pengunjung terhadap penyakit menular</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Partahankan teknik aspesis pada pasien yang beresiko</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Pertahankan teknik isolasi k/p</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Berikan perawatan kuliat pada area epidema</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Inspeksi kulit dan membran mukosa terhadap kemerahan,
panas, drainase</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Ispeksi kondisi luka / insisi bedah</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Dorong masukkan nutrisi yang cukup</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Dorong masukan cairan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Dorong istirahat</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Instruksikan pasien untuk minum antibiotik sesuai resep</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Ajarkan pasien dan keluarga tanda dan gejala infeksi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Ajarkan cara menghindari infeksi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Laporkan kecurigaan infeksi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Laporkan kultur positif</span></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 3.5%;" valign="top" width="3%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
3</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 31.44%;" valign="top" width="31%">
<div class="MsoNormal">
<span style="font-size: small;"><span>Resiko ketidakseimbangan nutrisi lebih dari
kebutuhan tubuh b/d peningkatan</span><span> </span><span>nafsu
makan</span></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 29.12%;" valign="top" width="29%">
<div class="MsoNormal">
<span style="font-size: small;"><b>NOC :</b></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Nutritional Status : food and
Fluid Intake</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><b>Kriteria
Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Adanya peningkatan berat
badan sesuai dengan tujuan</span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Berat badan ideal sesuai
dengan tinggi badan</span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Mampu mengidentifikasi
kebutuhan nutrisi</span></div>
<div class="MsoNormal" style="margin-left: 0.05in;">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 35.94%;" valign="top" width="35%">
<div class="MsoNormal">
<span style="font-size: small;"><b>Nutrition
Management</b></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Kaji adanya alergi makanan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Kolaborasi dengan ahli gizi untuk menentukan jumlah kalori dan nutrisi
yang dibutuhkan pasien.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Anjurkan pasien untuk meningkatkan intake Fe</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Anjurkan pasien untuk meningkatkan protein dan vitamin C</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan substansi gula</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Yakinkan diet yang dimakan mengandung tinggi serat untuk mencegah
konstipasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan makanan yang terpilih ( sudah dikonsultasikan dengan ahli
gizi)</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Ajarkan pasien bagaimana membuat catatan makanan harian.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor jumlah nutrisi dan kandungan kalori</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan informasi tentang kebutuhan nutrisi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Kaji kemampuan pasien untuk mendapatkan nutrisi yang dibutuhkan</span></span></div>
<div class="MsoNormal" style="margin-left: 3.55pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><b>Nutrition
Monitoring</b></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>BB pasien dalam batas normal</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor adanya penurunan berat badan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor tipe dan jumlah aktivitas yang biasa dilakukan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor interaksi anak atau orangtua selama makan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor lingkungan selama makan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Jadwalkan pengobatan<span> </span>dan
tindakan tidak selama jam makan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor kulit kering dan perubahan pigmentasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor turgor kulit</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor kekeringan, rambut kusam, dan mudah patah</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor mual dan muntah</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor kadar albumin, total protein, Hb, dan kadar Ht</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor makanan kesukaan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor pertumbuhan dan perkembangan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor pucat, kemerahan, dan kekeringan jaringan konjungtiva</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor kalori dan intake nuntrisi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Catat adanya edema,
hiperemik, hipertonik papila lidah dan cavitas oral.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Catat jika lidah
berwarna magenta, scarlet</span></span></div>
<div class="MsoNormal" style="margin-left: 3.55pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 3.5%;" valign="top" width="3%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
4</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 31.44%;" valign="top" width="31%">
<div class="MsoNormal">
<span style="font-size: small;"><span>PK : Anemia</span></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 29.12%;" valign="top" width="29%">
<div class="MsoNormal">
<span style="font-size: small;">
Perawat
dapat melakukan pencegahan untuk meminimalkan terjadinya anemia berkelanjutan</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 35.94%;" valign="top" width="35%">
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>1.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Pantau tanda dan gejala
anemia</span></span></div>
<div class="MsoNormal" style="margin-left: 48.65pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Adanya
letargi</span></span></div>
<div class="MsoNormal" style="margin-left: 48.65pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Adanya
kelemahan</span></span></div>
<div class="MsoNormal" style="margin-left: 48.65pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Keletihan</span></span></div>
<div class="MsoNormal" style="margin-left: 48.65pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Peningkatan
pucat</span></span></div>
<div class="MsoNormal" style="margin-left: 48.65pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Dyspneu
saat melakukan aktivitas</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>2.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Monitor kadar Hb</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;"><span>3.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Kolaborasi perlunya pemberian
transfusi</span></span></div>
</td></tr>
</tbody></table>
ERFANSYAH. HRhttp://www.blogger.com/profile/07497970584312798191noreply@blogger.com0tag:blogger.com,1999:blog-2228299828902052163.post-85601740273435107762012-11-20T20:44:00.003-08:002013-03-11T10:03:24.347-07:00Asuhan Keperawatan Asfiksia Neonatorum Menggunakan NANDA, NIC, NOC<h3 class="post-title entry-title" itemprop="name" style="font-family: Times,"Times New Roman",serif;">
<span style="font-size: small;">
Asuhan Keperawatan Asfiksia Neonatorum Menggunakan NANDA, NIC, NOC
</span></h3>
<span style="font-size: small;"><span style="font-family: Times,"Times New Roman",serif;">
</span></span><span style="font-size: small;"><span style="font-family: Times,"Times New Roman",serif;">
</span><span style="font-family: Times,"Times New Roman",serif;">
</span><b style="font-family: Times,"Times New Roman",serif;"><span style="line-height: 150%;"></span></b></span>
<h3 style="font-family: Times,"Times New Roman",serif;">
<span style="font-size: small;"><span><span>A.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span>Masalah
Yang lazim muncul pada klien</span></h3>
<span style="font-size: small;"><span style="font-family: Times,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Times,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>1.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Pola
nafas tidak efektif b/d kelemahan otot pernafasan</span></div>
<span style="font-size: small;"><span style="font-family: Times,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Times,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>2.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Bersihan
jalan nafas tidak efektif b/d obstruksi lendir</span></div>
<span style="font-size: small;"><span style="font-family: Times,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Times,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span>3.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Ketidakseimbangan
nutrisi kurang dar ikebutuhan tubuh b/d kelemahan</span></div>
<span style="font-size: small;"><span style="font-family: Times,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Times,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span>4.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Hipotermi
b/d paparan lingkungan dingin, BBL</span></div>
<span style="font-size: small;"><span style="font-family: Times,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Times,"Times New Roman",serif; line-height: 150%;">
<span style="font-size: small;"><br /></span></div>
<span style="font-size: small;"><span style="font-family: Times,"Times New Roman",serif;">
</span></span>
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: medium none; font-family: Times,"Times New Roman",serif; width: 100%;"><tbody>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>No</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 32.4%;" valign="top" width="32%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>Diagnosa
keperawatan</span></span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 32.52%;" valign="top" width="32%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>Tujuan
dan Kriteria Hasil</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 29.88%;" valign="top" width="29%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>Intervensi</span></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
1</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 32.4%;" valign="top" width="32%">
<div class="MsoBodyText3">
<span style="font-size: small;">
Pola nafas tidak efektif b/d kelemahan otot pernafasan</span></div>
<div class="MsoBodyText3">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : Pertukaran udara inspirasi dan/atau ekspirasi tidak
adekuat</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Batasan karakteristik : </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Penurunan tekanan inspirasi/ekspirasi </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Penurunan pertukaran udara per menit </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Menggunakan otot pernafasan tambahan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Nasal flaring </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Dyspnea</span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Orthopnea </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perubahan penyimpangan dada </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Nafas pendek </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Assumption of 3-point position </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Pernafasan pursed-lip </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Tahap ekspirasi berlangsung sangat lama </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Peningkatan diameter anterior-posterior </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Pernafasan rata-rata/minimal </span></span></div>
<div class="MsoNormal" style="margin-left: 31.85pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Bayi : < 25 atau >
60</span></span></div>
<div class="MsoNormal" style="margin-left: 31.85pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Usia 1-4 : < 20 atau
> 30</span></span></div>
<div class="MsoNormal" style="margin-left: 31.85pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Usia 5-14 : < 14 atau
> 25</span></span></div>
<div class="MsoNormal" style="margin-left: 31.85pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Usia > 14 : < 11
atau > 24</span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kedalaman pernafasan </span></span></div>
<div class="MsoNormal" style="margin-left: 31.85pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Dewasa volume tidalnya
500 ml saat istirahat </span></span></div>
<div class="MsoNormal" style="margin-left: 31.85pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Bayi volume tidalnya 6-8
ml/Kg</span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Timing rasio </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Penurunan kapasitas vital</span><span lang="NO-BOK"></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Faktor yang berhubungan : </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Hiperventilasi </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Deformitas tulang </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kelainan bentuk dinding dada </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Penurunan energi/kelelahan </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perusakan/pelemahan muskulo-skeletal </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Obesitas </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Posisi tubuh </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kelelahan otot pernafasan </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Hipoventilasi sindrom </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Nyeri </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kecemasan </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Disfungsi Neuromuskuler </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kerusakan persepsi/kognitif </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perlukaan pada jaringan syaraf tulang belakang </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Imaturitas Neurologis</span><span lang="NO-BOK"></span></span></div>
<div class="MsoBodyText3">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 32.52%;" valign="top" width="32%">
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NOC : </b></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Respiratory
status : Ventilation</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Respiratory
status : Airway patency</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Vital
sign Status</span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 21.5pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Mendemonstrasikan batuk efektif dan suara nafas
yang bersih, tidak ada sianosis dan dyspneu (mampu mengeluarkan sputum, mampu
bernafas dengan mudah, tidak ada pursed lips)</span></span></div>
<div class="MsoNormal" style="margin-left: 21.5pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Menunjukkan
jalan nafas yang paten</span><span> (</span><span>klien tidak merasa tercekik, irama nafas,
frekuensi pernafasan dalam rentang normal, tidak ada suara nafas abnormal)</span></span></div>
<div class="MsoNormal" style="margin-left: 21.5pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="IT">Tanda Tanda vital dalam
rentang normal (tekanan darah, nadi, pernafasan</span><span lang="IT"></span></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 29.88%;" valign="top" width="29%">
<h1>
<span style="font-size: small;">
Airway Management</span></h1>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Buka jalan nafas, guanakan teknik chin lift atau jaw
thrust bila perlu</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Posisikan pasien untuk memaksimalkan ventilasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Identifikasi pasien perlunya pemasangan alat jalan
nafas buatan </span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Pasang mayo bila perlu</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Lakukan fisioterapi dada jika perlu</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Keluarkan sekret dengan batuk atau suction</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Auskultasi suara nafas, catat adanya suara tambahan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Lakukan suction pada mayo</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Berikan bronkodilator bila perlu</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Berikan pelembab udara Kassa basah NaCl Lembab</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Atur intake untuk cairan mengoptimalkan keseimbangan.</span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="FR">Monitor respirasi dan status O2</span></span></div>
<div class="MsoNormal" style="margin-left: 3.55pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="margin-left: 3.8pt; text-align: justify;">
<span style="font-size: small;"><b>Oxygen Therapy</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Bersihkan mulut, hidung dan secret trakea</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Pertahankan jalan nafas yang
paten</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Atur peralatan oksigenasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Monitor aliran oksigen</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Pertahankan posisi pasien</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Onservasi
adanya tanda tanda hipoventilasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Monitor adanya kecemasan pasien terhadap oksigenasi</span></span></div>
<div class="MsoNormal" style="margin-left: 3.8pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="margin-left: 3.8pt; text-align: justify;">
<span style="font-size: small;"><b>Vital sign Monitoring</b></span></div>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span lang="NL">Monitor TD, nadi, suhu, dan RR</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Catat adanya fluktuasi tekanan darah</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span lang="NL">Monitor VS saat pasien berbaring, duduk, atau berdiri</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span lang="NL">Auskultasi TD pada kedua lengan dan bandingkan</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Monitor TD, nadi, RR, sebelum, selama, dan
setelah aktivitas</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Monitor kualitas dari nadi</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Monitor frekuensi dan irama pernapasan</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Monitor suara paru</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Monitor pola pernapasan abnormal</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span lang="NL">Monitor suhu, warna, dan kelembaban kulit</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Monitor sianosis perifer</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Monitor adanya cushing triad (tekanan nadi
yang melebar, bradikardi, peningkatan sistolik)</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span lang="IT">Identifikasi penyebab dari perubahan vital sign</span><span lang="IT"></span></span></li>
</ul>
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<span style="font-size: small;"><br /></span></div>
</td>
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<span style="font-size: small;">
2</span></div>
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<div class="MsoBodyText3">
<span style="font-size: small;">
Bersihan jalan nafas tidak efektif b/d obstruksi lendir</span></div>
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<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : Ketidakmampuan
untuk membersihkan sekresi atau obstruksi dari saluran pernafasan untuk
mempertahankan kebersihan jalan nafas.</span></span></div>
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<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span style="font-size: small;"><span lang="NO-BOK" style="line-height: 150%;">Batasan Karakteristik :</span></span></div>
<div class="MsoNormal" style="margin-left: 23.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Dispneu, Penurunan
suara nafas</span></span></div>
<div class="MsoNormal" style="margin-left: 23.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Orthopneu</span></span></div>
<div class="MsoNormal" style="margin-left: 23.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Cyanosis</span></span></div>
<div class="MsoNormal" style="margin-left: 23.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kelainan suara
nafas (rales, wheezing)</span></span></div>
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<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kesulitan
berbicara</span></span></div>
<div class="MsoNormal" style="margin-left: 23.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Batuk, tidak
efekotif atau tidak ada</span></span></div>
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<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Mata melebar</span></span></div>
<div class="MsoNormal" style="margin-left: 23.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Produksi sputum</span></span></div>
<div class="MsoNormal" style="margin-left: 23.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Gelisah</span></span></div>
<div class="MsoNormal" style="margin-left: 23.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perubahan
frekuensi dan irama nafas</span></span></div>
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<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span style="font-size: small;"><span lang="NO-BOK" style="line-height: 150%;">Faktor-faktor yang berhubungan: </span></span></div>
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<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Lingkungan : merokok,
menghirup asap rokok, perokok pasif-POK, infeksi</span></span></div>
<div class="MsoNormal" style="margin-left: 23.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Fisiologis :
disfungsi neuromuskular, hiperplasia dinding bronkus, alergi jalan nafas,
asma.</span></span></div>
<div class="MsoNormal" style="margin-left: 23.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Obstruksi jalan
nafas : spasme jalan nafas, sekresi tertahan, banyaknya mukus, adanya jalan
nafas buatan, sekresi bronkus, adanya eksudat di alveolus, adanya benda asing
di jalan nafas.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 32.52%;" valign="top" width="32%">
<div class="MsoNormal">
<span style="font-size: small;"><span>NOC : </span></span></div>
<div class="MsoNormal" style="margin-left: 26.45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Respiratory
status : Ventilation</span></span></div>
<div class="MsoNormal" style="margin-left: 26.45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Respiratory
status : Airway patency</span></span></div>
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<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;">
Kriteria
Hasil :</span></div>
<div class="MsoNormal" style="margin-left: 21.5pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Mendemonstrasikan batuk efektif dan suara nafas
yang bersih, tidak ada sianosis dan dyspneu (mampu mengeluarkan sputum, mampu
bernafas dengan mudah, tidak ada pursed lips)</span></span></div>
<div class="MsoNormal" style="margin-left: 21.5pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Menunjukkan
jalan nafas yang paten</span><span> (</span><span>klien tidak merasa tercekik, irama nafas,
frekuensi pernafasan dalam rentang normal, tidak ada suara nafas abnormal)</span></span></div>
<div class="MsoNormal" style="margin-left: 21.5pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NL">Mampu mengidentifikasikan
dan mencegah factor yang dapat menghambat jalan nafas</span><span lang="NL"></span></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 29.88%;" valign="top" width="29%">
<div class="MsoHeading7" style="line-height: normal;">
<span style="font-size: small;">
Airway suction</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Pastikan kebutuhan oral / tracheal suctioning</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span><span> </span>Auskultasi suara nafas sebelum
dan sesudah suctioning.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Informasikan pada klien dan
keluarga tentang suctioning</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Minta klien nafas dalam sebelum suction dilakukan.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan O2 dengan menggunakan nasal untuk memfasilitasi suksion
nasotrakeal</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Gunakan alat yang steril
sitiap melakukan tindakan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Anjurkan pasien untuk
istirahat dan napas dalam setelah kateter dikeluarkan dari nasotrakeal</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor status oksigen pasien</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Ajarkan keluarga bagaimana cara melakukan suksion</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NL">Hentikan suksion dan berikan
oksigen apabila pasien menunjukkan bradikardi, peningkatan saturasi O2, dll.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoHeading7" style="line-height: normal;">
<span style="font-size: small;">
Airway Management</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Buka jalan nafas, guanakan teknik chin lift atau jaw thrust
bila perlu</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Posisikan pasien untuk memaksimalkan ventilasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Identifikasi pasien perlunya pemasangan alat jalan
nafas buatan </span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Pasang mayo bila perlu</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Lakukan fisioterapi dada jika perlu</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Keluarkan sekret dengan batuk atau suction</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Auskultasi suara nafas, catat adanya suara tambahan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Lakukan suction pada mayo</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Berikan bronkodilator bila perlu</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Berikan pelembab udara Kassa basah NaCl Lembab</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="FR">Atur intake untuk cairan mengoptimalkan keseimbangan.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="FR">Monitor respirasi dan status O2</span></span></div>
<div class="MsoNormal" style="margin-left: 3.55pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
3</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 32.4%;" valign="top" width="32%">
<div class="MsoNormal">
<span style="font-size: small;"><span>Ketidakseimbangan nutrisi kurang dari
kebutuhan tubuh b/d kelemahan</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : Intake nutrisi tidak cukup untuk
keperluan metabolisme tubuh.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Batasan karakteristik : </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Berat badan 20 % atau lebih di bawah ideal </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Dilaporkan adanya intake makanan yang kurang
dari RDA (Recomended Daily Allowance) </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Membran mukosa dan konjungtiva pucat </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kelemahan otot yang digunakan untuk
menelan/mengunyah </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Luka, inflamasi pada rongga mulut </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Mudah merasa kenyang, sesaat setelah
mengunyah makanan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Dilaporkan atau fakta adanya kekurangan
makanan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Dilaporkan adanya perubahan sensasi rasa </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perasaan ketidakmampuan untuk mengunyah
makanan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Miskonsepsi </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kehilangan BB dengan makanan cukup </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Keengganan untuk makan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kram pada abdomen </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Tonus otot jelek </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Nyeri abdominal dengan atau tanpa patologi </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kurang berminat terhadap makanan</span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Pembuluh darah kapiler mulai rapuh </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Diare dan atau steatorrhea </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kehilangan rambut yang cukup banyak (rontok) </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Suara usus hiperaktif</span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Kurangnya informasi, misinformasi</span><span></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Faktor-faktor yang berhubungan : </span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Ketidakmampuan pemasukan atau mencerna makanan atau
mengabsorpsi zat-zat gizi berhubungan dengan faktor biologis, psikologis atau
ekonomi.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 32.52%;" valign="top" width="32%">
<div class="MsoNormal">
<span style="font-size: small;"><b>NOC :</b></span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Nutritional
Status : </span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Nutritional
Status : food and Fluid Intake</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Nutritional
Status : nutrient Intake</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Weight
control</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><b>Kriteria
Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Adanya
peningkatan berat badan sesuai dengan tujuan</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Beratbadan
ideal sesuai dengan tinggi badan</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Mampumengidentifikasi
kebutuhan nutrisi</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Tidk
ada tanda tanda malnutrisi</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Menunjukkan
peningkatan fungsi pengecapan dari menelan</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Tidak terjadi penurunan berat badan yang berarti</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 29.88%;" valign="top" width="29%">
<div class="MsoNormal">
<span style="font-size: small;"><b>Nutrition
Management</b></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Kaji adanya alergi makanan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Kolaborasi dengan ahli gizi untuk menentukan jumlah kalori dan nutrisi
yang dibutuhkan pasien.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Anjurkan pasien untuk
meningkatkan intake Fe</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Anjurkan pasien untuk
meningkatkan protein dan vitamin C</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan substansi gula</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Yakinkan diet yang dimakan
mengandung tinggi serat untuk mencegah konstipasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Berikan makanan yang
terpilih ( sudah dikonsultasikan dengan ahli gizi)</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Ajarkan pasien bagaimana membuat catatan makanan harian.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Monitor jumlah nutrisi dan
kandungan kalori</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan informasi tentang kebutuhan nutrisi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Kaji kemampuan pasien untuk mendapatkan nutrisi yang dibutuhkan</span></span></div>
<div class="MsoNormal" style="margin-left: 3.55pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><b>Nutrition
Monitoring</b></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>BB pasien dalam batas normal</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor adanya penurunan berat badan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Monitor tipe dan jumlah
aktivitas yang biasa dilakukan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="IT"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="IT">Monitor interaksi anak atau
orangtua selama makan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor lingkungan selama makan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Jadwalkan pengobatan<span> </span>dan tindakan tidak selama jam makan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Monitor kulit kering dan
perubahan pigmentasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor turgor kulit</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Monitor kekeringan, rambut
kusam, dan mudah patah</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor mual dan muntah</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Monitor kadar albumin, total
protein, Hb, dan kadar Ht</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor makanan kesukaan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor pertumbuhan dan perkembangan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Monitor pucat, kemerahan,
dan kekeringan jaringan konjungtiva</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor kalori dan intake nuntrisi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Catat adanya edema,
hiperemik, hipertonik papila lidah dan cavitas oral.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="IT">Catat jika lidah berwarna
magenta, scarlet</span><span lang="IT"></span></span></div>
<div class="MsoNormal" style="margin-left: 3.55pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
4</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 32.4%;" valign="top" width="32%">
<div class="MsoBodyText3">
<span style="font-size: small;">
Hipotermi b/d paparan lingkungan dingin, BBL</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 32.52%;" valign="top" width="32%">
<div class="MsoNormal">
<span style="font-size: small;"><b>NOC : </b></span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Thermoregulation</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Thermoregulation
: neonate</span></div>
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Suhu tubuh dalam rentang normal</span></div>
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Nadi dan RR dalam rentang normal</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 29.88%;" valign="top" width="29%">
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;">
NIC :<span></span></span></div>
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>Temperature
regulation</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor suhu minimal tiap 2 jam</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Rencanakan monitoring suhu secara kontinyu</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor TD, nadi, dan RR</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor warna dan suhu kulit</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor tanda-tanda hipertermi dan hipotermi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Tingkatkan intake cairan dan nutrisi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Selimuti pasien untuk mencegah hilangnya kehangatan tubuh</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Ajarkan pada pasien cara mencegah keletihan akibat panas</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Diskusikan tentang pentingnya pengaturan suhu dan kemungkinan efek
negatif dari kedinginan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Beritahukan tentang indikasi terjadinya keletihan dan penanganan
emergency yang diperlukan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Ajarkan indikasi dari hipotermi dan penanganan yang diperlukan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan anti piretik jika perlu</span></span></div>
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>Vital
sign Monitoring</b></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor TD, nadi, suhu, dan RR</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Catat adanya fluktuasi tekanan darah</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor VS saat pasien berbaring, duduk, atau berdiri</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Auskultasi TD pada kedua lengan dan bandingkan</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor TD, nadi, RR, sebelum, selama, dan setelah aktivitas</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor kualitas dari nadi</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor frekuensi dan irama pernapasan</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor suara paru</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor pola pernapasan abnormal</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor suhu, warna, dan kelembaban kulit</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor sianosis perifer</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Monitor
adanya cushing triad (tekanan nadi yang melebar, bradikardi, peningkatan
sistolik)</span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="IT"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="IT">Identifikasi penyebab dari perubahan vital sign</span></span></div>
</td></tr>
</tbody></table>
ERFANSYAH. HRhttp://www.blogger.com/profile/07497970584312798191noreply@blogger.com0tag:blogger.com,1999:blog-2228299828902052163.post-49978887647111432202012-11-20T20:44:00.001-08:002013-03-11T10:03:24.319-07:00Asuhan Keperawatan Asfiksia Neonatorum Menggunakan NANDA, NIC, NOC<h3 class="post-title entry-title" itemprop="name" style="font-family: Times,"Times New Roman",serif;">
<span style="font-size: small;">
Asuhan Keperawatan Asfiksia Neonatorum Menggunakan NANDA, NIC, NOC
</span></h3>
<span style="font-size: small;"><span style="font-family: Times,"Times New Roman",serif;">
</span></span><span style="font-size: small;"><span style="font-family: Times,"Times New Roman",serif;">
</span><span style="font-family: Times,"Times New Roman",serif;">
</span><b style="font-family: Times,"Times New Roman",serif;"><span style="line-height: 150%;"></span></b></span>
<h3 style="font-family: Times,"Times New Roman",serif;">
<span style="font-size: small;"><span><span>A.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span>Masalah
Yang lazim muncul pada klien</span></h3>
<span style="font-size: small;"><span style="font-family: Times,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Times,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>1.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Pola
nafas tidak efektif b/d kelemahan otot pernafasan</span></div>
<span style="font-size: small;"><span style="font-family: Times,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Times,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>2.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Bersihan
jalan nafas tidak efektif b/d obstruksi lendir</span></div>
<span style="font-size: small;"><span style="font-family: Times,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Times,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span>3.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Ketidakseimbangan
nutrisi kurang dar ikebutuhan tubuh b/d kelemahan</span></div>
<span style="font-size: small;"><span style="font-family: Times,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Times,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span>4.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Hipotermi
b/d paparan lingkungan dingin, BBL</span></div>
<span style="font-size: small;"><span style="font-family: Times,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Times,"Times New Roman",serif; line-height: 150%;">
<span style="font-size: small;"><br /></span></div>
<span style="font-size: small;"><span style="font-family: Times,"Times New Roman",serif;">
</span></span>
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: medium none; font-family: Times,"Times New Roman",serif; width: 100%;"><tbody>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>No</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 32.4%;" valign="top" width="32%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>Diagnosa
keperawatan</span></span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 32.52%;" valign="top" width="32%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>Tujuan
dan Kriteria Hasil</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 29.88%;" valign="top" width="29%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>Intervensi</span></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
1</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 32.4%;" valign="top" width="32%">
<div class="MsoBodyText3">
<span style="font-size: small;">
Pola nafas tidak efektif b/d kelemahan otot pernafasan</span></div>
<div class="MsoBodyText3">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : Pertukaran udara inspirasi dan/atau ekspirasi tidak
adekuat</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Batasan karakteristik : </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Penurunan tekanan inspirasi/ekspirasi </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Penurunan pertukaran udara per menit </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Menggunakan otot pernafasan tambahan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Nasal flaring </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Dyspnea</span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Orthopnea </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perubahan penyimpangan dada </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Nafas pendek </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Assumption of 3-point position </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Pernafasan pursed-lip </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Tahap ekspirasi berlangsung sangat lama </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Peningkatan diameter anterior-posterior </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Pernafasan rata-rata/minimal </span></span></div>
<div class="MsoNormal" style="margin-left: 31.85pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Bayi : < 25 atau >
60</span></span></div>
<div class="MsoNormal" style="margin-left: 31.85pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Usia 1-4 : < 20 atau
> 30</span></span></div>
<div class="MsoNormal" style="margin-left: 31.85pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Usia 5-14 : < 14 atau
> 25</span></span></div>
<div class="MsoNormal" style="margin-left: 31.85pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Usia > 14 : < 11
atau > 24</span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kedalaman pernafasan </span></span></div>
<div class="MsoNormal" style="margin-left: 31.85pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Dewasa volume tidalnya
500 ml saat istirahat </span></span></div>
<div class="MsoNormal" style="margin-left: 31.85pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Bayi volume tidalnya 6-8
ml/Kg</span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Timing rasio </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Penurunan kapasitas vital</span><span lang="NO-BOK"></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Faktor yang berhubungan : </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Hiperventilasi </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Deformitas tulang </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kelainan bentuk dinding dada </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Penurunan energi/kelelahan </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perusakan/pelemahan muskulo-skeletal </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Obesitas </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Posisi tubuh </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kelelahan otot pernafasan </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Hipoventilasi sindrom </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Nyeri </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kecemasan </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Disfungsi Neuromuskuler </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kerusakan persepsi/kognitif </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perlukaan pada jaringan syaraf tulang belakang </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Imaturitas Neurologis</span><span lang="NO-BOK"></span></span></div>
<div class="MsoBodyText3">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 32.52%;" valign="top" width="32%">
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NOC : </b></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Respiratory
status : Ventilation</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Respiratory
status : Airway patency</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Vital
sign Status</span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 21.5pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Mendemonstrasikan batuk efektif dan suara nafas
yang bersih, tidak ada sianosis dan dyspneu (mampu mengeluarkan sputum, mampu
bernafas dengan mudah, tidak ada pursed lips)</span></span></div>
<div class="MsoNormal" style="margin-left: 21.5pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Menunjukkan
jalan nafas yang paten</span><span> (</span><span>klien tidak merasa tercekik, irama nafas,
frekuensi pernafasan dalam rentang normal, tidak ada suara nafas abnormal)</span></span></div>
<div class="MsoNormal" style="margin-left: 21.5pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="IT">Tanda Tanda vital dalam
rentang normal (tekanan darah, nadi, pernafasan</span><span lang="IT"></span></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 29.88%;" valign="top" width="29%">
<h1>
<span style="font-size: small;">
Airway Management</span></h1>
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<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Buka jalan nafas, guanakan teknik chin lift atau jaw
thrust bila perlu</span></span></div>
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<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Posisikan pasien untuk memaksimalkan ventilasi</span></span></div>
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<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Identifikasi pasien perlunya pemasangan alat jalan
nafas buatan </span></span></div>
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<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Pasang mayo bila perlu</span></span></div>
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<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Lakukan fisioterapi dada jika perlu</span></span></div>
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<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Keluarkan sekret dengan batuk atau suction</span></span></div>
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<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Auskultasi suara nafas, catat adanya suara tambahan</span></span></div>
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<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Lakukan suction pada mayo</span></span></div>
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<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Berikan bronkodilator bila perlu</span></span></div>
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<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Berikan pelembab udara Kassa basah NaCl Lembab</span></span></div>
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<span style="font-size: small;"><span><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Atur intake untuk cairan mengoptimalkan keseimbangan.</span><span></span></span></div>
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<span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="FR">Monitor respirasi dan status O2</span></span></div>
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<span style="font-size: small;"><br /></span></div>
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<span style="font-size: small;"><b>Oxygen Therapy</b></span></div>
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<span style="font-size: small;"><span lang="NL"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Bersihkan mulut, hidung dan secret trakea</span></span></div>
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<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Pertahankan jalan nafas yang
paten</span></span></div>
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<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Atur peralatan oksigenasi</span></span></div>
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<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Monitor aliran oksigen</span></span></div>
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<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Pertahankan posisi pasien</span></span></div>
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<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Onservasi
adanya tanda tanda hipoventilasi</span></span></div>
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<span style="font-size: small;"><span lang="NL"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Monitor adanya kecemasan pasien terhadap oksigenasi</span></span></div>
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<span style="font-size: small;"><br /></span></div>
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<span style="font-size: small;"><b>Vital sign Monitoring</b></span></div>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span lang="NL">Monitor TD, nadi, suhu, dan RR</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Catat adanya fluktuasi tekanan darah</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span lang="NL">Monitor VS saat pasien berbaring, duduk, atau berdiri</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span lang="NL">Auskultasi TD pada kedua lengan dan bandingkan</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Monitor TD, nadi, RR, sebelum, selama, dan
setelah aktivitas</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Monitor kualitas dari nadi</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Monitor frekuensi dan irama pernapasan</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Monitor suara paru</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Monitor pola pernapasan abnormal</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span lang="NL">Monitor suhu, warna, dan kelembaban kulit</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Monitor sianosis perifer</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Monitor adanya cushing triad (tekanan nadi
yang melebar, bradikardi, peningkatan sistolik)</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span lang="IT">Identifikasi penyebab dari perubahan vital sign</span><span lang="IT"></span></span></li>
</ul>
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<span style="font-size: small;">
2</span></div>
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<span style="font-size: small;">
Bersihan jalan nafas tidak efektif b/d obstruksi lendir</span></div>
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<span style="font-size: small;"><br /></span></div>
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<span style="font-size: small;"><span lang="NO-BOK">Definisi : Ketidakmampuan
untuk membersihkan sekresi atau obstruksi dari saluran pernafasan untuk
mempertahankan kebersihan jalan nafas.</span></span></div>
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<span style="font-size: small;"><br /></span></div>
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<span style="font-size: small;"><span lang="NO-BOK" style="line-height: 150%;">Batasan Karakteristik :</span></span></div>
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<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Dispneu, Penurunan
suara nafas</span></span></div>
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<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Orthopneu</span></span></div>
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<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Cyanosis</span></span></div>
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<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kelainan suara
nafas (rales, wheezing)</span></span></div>
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<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kesulitan
berbicara</span></span></div>
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<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Batuk, tidak
efekotif atau tidak ada</span></span></div>
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<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Mata melebar</span></span></div>
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<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Produksi sputum</span></span></div>
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<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Gelisah</span></span></div>
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<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perubahan
frekuensi dan irama nafas</span></span></div>
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<span style="font-size: small;"><br /></span></div>
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<span style="font-size: small;"><span lang="NO-BOK" style="line-height: 150%;">Faktor-faktor yang berhubungan: </span></span></div>
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<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Lingkungan : merokok,
menghirup asap rokok, perokok pasif-POK, infeksi</span></span></div>
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<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Fisiologis :
disfungsi neuromuskular, hiperplasia dinding bronkus, alergi jalan nafas,
asma.</span></span></div>
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<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Obstruksi jalan
nafas : spasme jalan nafas, sekresi tertahan, banyaknya mukus, adanya jalan
nafas buatan, sekresi bronkus, adanya eksudat di alveolus, adanya benda asing
di jalan nafas.</span></span></div>
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<span style="font-size: small;"><br /></span></div>
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<span style="font-size: small;"><span>NOC : </span></span></div>
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<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Respiratory
status : Ventilation</span></span></div>
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<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Respiratory
status : Airway patency</span></span></div>
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<span style="font-size: small;"><br /></span></div>
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Kriteria
Hasil :</span></div>
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<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Mendemonstrasikan batuk efektif dan suara nafas
yang bersih, tidak ada sianosis dan dyspneu (mampu mengeluarkan sputum, mampu
bernafas dengan mudah, tidak ada pursed lips)</span></span></div>
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<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Menunjukkan
jalan nafas yang paten</span><span> (</span><span>klien tidak merasa tercekik, irama nafas,
frekuensi pernafasan dalam rentang normal, tidak ada suara nafas abnormal)</span></span></div>
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<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NL">Mampu mengidentifikasikan
dan mencegah factor yang dapat menghambat jalan nafas</span><span lang="NL"></span></span></div>
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<span style="font-size: small;">
Airway suction</span></div>
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<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Pastikan kebutuhan oral / tracheal suctioning</span></span></div>
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<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span><span> </span>Auskultasi suara nafas sebelum
dan sesudah suctioning.</span></span></div>
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<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Informasikan pada klien dan
keluarga tentang suctioning</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Minta klien nafas dalam sebelum suction dilakukan.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan O2 dengan menggunakan nasal untuk memfasilitasi suksion
nasotrakeal</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Gunakan alat yang steril
sitiap melakukan tindakan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Anjurkan pasien untuk
istirahat dan napas dalam setelah kateter dikeluarkan dari nasotrakeal</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor status oksigen pasien</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Ajarkan keluarga bagaimana cara melakukan suksion</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NL">Hentikan suksion dan berikan
oksigen apabila pasien menunjukkan bradikardi, peningkatan saturasi O2, dll.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoHeading7" style="line-height: normal;">
<span style="font-size: small;">
Airway Management</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Buka jalan nafas, guanakan teknik chin lift atau jaw thrust
bila perlu</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Posisikan pasien untuk memaksimalkan ventilasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Identifikasi pasien perlunya pemasangan alat jalan
nafas buatan </span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Pasang mayo bila perlu</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Lakukan fisioterapi dada jika perlu</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Keluarkan sekret dengan batuk atau suction</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Auskultasi suara nafas, catat adanya suara tambahan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Lakukan suction pada mayo</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Berikan bronkodilator bila perlu</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Berikan pelembab udara Kassa basah NaCl Lembab</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="FR">Atur intake untuk cairan mengoptimalkan keseimbangan.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="FR">Monitor respirasi dan status O2</span></span></div>
<div class="MsoNormal" style="margin-left: 3.55pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
3</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 32.4%;" valign="top" width="32%">
<div class="MsoNormal">
<span style="font-size: small;"><span>Ketidakseimbangan nutrisi kurang dari
kebutuhan tubuh b/d kelemahan</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : Intake nutrisi tidak cukup untuk
keperluan metabolisme tubuh.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Batasan karakteristik : </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Berat badan 20 % atau lebih di bawah ideal </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Dilaporkan adanya intake makanan yang kurang
dari RDA (Recomended Daily Allowance) </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Membran mukosa dan konjungtiva pucat </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kelemahan otot yang digunakan untuk
menelan/mengunyah </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Luka, inflamasi pada rongga mulut </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Mudah merasa kenyang, sesaat setelah
mengunyah makanan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Dilaporkan atau fakta adanya kekurangan
makanan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Dilaporkan adanya perubahan sensasi rasa </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perasaan ketidakmampuan untuk mengunyah
makanan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Miskonsepsi </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kehilangan BB dengan makanan cukup </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Keengganan untuk makan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kram pada abdomen </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Tonus otot jelek </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Nyeri abdominal dengan atau tanpa patologi </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kurang berminat terhadap makanan</span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Pembuluh darah kapiler mulai rapuh </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Diare dan atau steatorrhea </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kehilangan rambut yang cukup banyak (rontok) </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Suara usus hiperaktif</span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Kurangnya informasi, misinformasi</span><span></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Faktor-faktor yang berhubungan : </span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Ketidakmampuan pemasukan atau mencerna makanan atau
mengabsorpsi zat-zat gizi berhubungan dengan faktor biologis, psikologis atau
ekonomi.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 32.52%;" valign="top" width="32%">
<div class="MsoNormal">
<span style="font-size: small;"><b>NOC :</b></span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Nutritional
Status : </span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Nutritional
Status : food and Fluid Intake</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Nutritional
Status : nutrient Intake</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Weight
control</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><b>Kriteria
Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Adanya
peningkatan berat badan sesuai dengan tujuan</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Beratbadan
ideal sesuai dengan tinggi badan</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Mampumengidentifikasi
kebutuhan nutrisi</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Tidk
ada tanda tanda malnutrisi</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Menunjukkan
peningkatan fungsi pengecapan dari menelan</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Tidak terjadi penurunan berat badan yang berarti</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 29.88%;" valign="top" width="29%">
<div class="MsoNormal">
<span style="font-size: small;"><b>Nutrition
Management</b></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Kaji adanya alergi makanan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Kolaborasi dengan ahli gizi untuk menentukan jumlah kalori dan nutrisi
yang dibutuhkan pasien.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Anjurkan pasien untuk
meningkatkan intake Fe</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Anjurkan pasien untuk
meningkatkan protein dan vitamin C</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan substansi gula</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Yakinkan diet yang dimakan
mengandung tinggi serat untuk mencegah konstipasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Berikan makanan yang
terpilih ( sudah dikonsultasikan dengan ahli gizi)</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Ajarkan pasien bagaimana membuat catatan makanan harian.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Monitor jumlah nutrisi dan
kandungan kalori</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan informasi tentang kebutuhan nutrisi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Kaji kemampuan pasien untuk mendapatkan nutrisi yang dibutuhkan</span></span></div>
<div class="MsoNormal" style="margin-left: 3.55pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><b>Nutrition
Monitoring</b></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>BB pasien dalam batas normal</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor adanya penurunan berat badan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Monitor tipe dan jumlah
aktivitas yang biasa dilakukan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="IT"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="IT">Monitor interaksi anak atau
orangtua selama makan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor lingkungan selama makan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Jadwalkan pengobatan<span> </span>dan tindakan tidak selama jam makan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Monitor kulit kering dan
perubahan pigmentasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor turgor kulit</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Monitor kekeringan, rambut
kusam, dan mudah patah</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor mual dan muntah</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Monitor kadar albumin, total
protein, Hb, dan kadar Ht</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor makanan kesukaan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor pertumbuhan dan perkembangan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Monitor pucat, kemerahan,
dan kekeringan jaringan konjungtiva</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor kalori dan intake nuntrisi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Catat adanya edema,
hiperemik, hipertonik papila lidah dan cavitas oral.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="IT">Catat jika lidah berwarna
magenta, scarlet</span><span lang="IT"></span></span></div>
<div class="MsoNormal" style="margin-left: 3.55pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
4</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 32.4%;" valign="top" width="32%">
<div class="MsoBodyText3">
<span style="font-size: small;">
Hipotermi b/d paparan lingkungan dingin, BBL</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 32.52%;" valign="top" width="32%">
<div class="MsoNormal">
<span style="font-size: small;"><b>NOC : </b></span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Thermoregulation</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Thermoregulation
: neonate</span></div>
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Suhu tubuh dalam rentang normal</span></div>
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Nadi dan RR dalam rentang normal</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 29.88%;" valign="top" width="29%">
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;">
NIC :<span></span></span></div>
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>Temperature
regulation</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor suhu minimal tiap 2 jam</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Rencanakan monitoring suhu secara kontinyu</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor TD, nadi, dan RR</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor warna dan suhu kulit</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor tanda-tanda hipertermi dan hipotermi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Tingkatkan intake cairan dan nutrisi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Selimuti pasien untuk mencegah hilangnya kehangatan tubuh</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Ajarkan pada pasien cara mencegah keletihan akibat panas</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Diskusikan tentang pentingnya pengaturan suhu dan kemungkinan efek
negatif dari kedinginan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Beritahukan tentang indikasi terjadinya keletihan dan penanganan
emergency yang diperlukan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Ajarkan indikasi dari hipotermi dan penanganan yang diperlukan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan anti piretik jika perlu</span></span></div>
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>Vital
sign Monitoring</b></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor TD, nadi, suhu, dan RR</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Catat adanya fluktuasi tekanan darah</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor VS saat pasien berbaring, duduk, atau berdiri</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Auskultasi TD pada kedua lengan dan bandingkan</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor TD, nadi, RR, sebelum, selama, dan setelah aktivitas</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor kualitas dari nadi</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor frekuensi dan irama pernapasan</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor suara paru</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor pola pernapasan abnormal</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor suhu, warna, dan kelembaban kulit</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor sianosis perifer</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Monitor
adanya cushing triad (tekanan nadi yang melebar, bradikardi, peningkatan
sistolik)</span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="IT"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="IT">Identifikasi penyebab dari perubahan vital sign</span></span></div>
</td></tr>
</tbody></table>
ERFANSYAH. HRhttp://www.blogger.com/profile/07497970584312798191noreply@blogger.com0tag:blogger.com,1999:blog-2228299828902052163.post-1897832987573829272012-11-20T20:40:00.001-08:002013-03-11T10:03:24.307-07:00Asuhan Keperawatan Febris / Demam Aplikasi NANDA, NIC, NOC <h3 class="post-title entry-title" itemprop="name" style="font-family: Georgia,"Times New Roman",serif;">
<span style="font-size: small;">
Asuhan Keperawatan Febris / Demam Aplikasi NANDA, NIC, NOC
</span></h3>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span>
<h3 style="font-family: Georgia,"Times New Roman",serif;">
<span style="font-size: small;"><span><span>A.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span>Masalah
Yang lazim muncul pada klien</span></h3>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>1.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="line-height: 150%;">Hipertemia b/d proses penyakit</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL" style="line-height: 150%;"><span>2.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL" style="line-height: 150%;">Resiko injury b/d infeksi mikroorganisme</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><b><i><span>3.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></i></b><span lang="NL" style="line-height: 150%;">Resiko defisit volume cairan b/d intake yang kurang dan
diaporesis</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 27pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><h3 style="font-family: Georgia,"Times New Roman",serif;">
<span style="font-size: small;"><span><span>B.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span>Discharge
Planning</span></h3>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 63pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL" style="line-height: 150%;"><span>1.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL" style="line-height: 150%;">Ajarkan pada orang tua mengenal tanda tanda kekambuhan
dan laporkan dokter /perawat</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 63pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL" style="line-height: 150%;"><span>2.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL" style="line-height: 150%;">Instruksikan untuk memberikan pengobatan sesuai denga
dosis dan waktu</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 63pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL" style="line-height: 150%;"><span>3.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL" style="line-height: 150%;">Ajarkan bagaimana mengukur suhu tubuh dan intervensi</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 63pt; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>4.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="line-height: 150%;">Instruksikan untuk kontrol ulang</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 63pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>5.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL" style="line-height: 150%;">Jelaskan factor penyebab
demam dan menghindari factor pencetus</span><span lang="NL"></span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 63pt;">
<span style="font-size: small;"><br /></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span>
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: medium none; font-family: Georgia,"Times New Roman",serif; width: 100%;"><tbody>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>No</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 37.42%;" valign="top" width="37%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>Diagnosa
keperawatan</span></span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 27.32%;" valign="top" width="27%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>Tujuan
dan Kriteria Hasil</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 30.06%;" valign="top" width="30%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>Intervensi</span></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
1</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 37.42%;" valign="top" width="37%">
<div class="MsoNormal" style="line-height: 150%;">
<span style="font-size: small;"><span style="line-height: 150%;">Hipertemia b/d proses penyakit</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : suhu tubuh naik diatas rentang normal</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Batasan Karakteristik:</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">kenaikan suhu tubuh diatas rentang normal</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">serangan atau konvulsi (kejang)</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">kulit kemerahan</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">pertambahan RR</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">takikardi</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">saat disentuh tangan terasa hangat</span></span></div>
<div class="MsoNormal" style="margin-left: 2.1pt;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Faktor faktor yang berhubungan :</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">penyakit/ trauma</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">peningkatan metabolisme</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">aktivitas yang berlebih</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">pengaruh medikasi/anastesi</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">ketidakmampuan/penurunan kemampuan untuk
berkeringat</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">terpapar dilingkungan panas</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">dehidrasi</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">pakaian yang tidak tepat</span></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 27.32%;" valign="top" width="27%">
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>NOC </b>: Thermoregulation</span></div>
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Suhu tubuh dalam rentang normal</span></div>
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Nadi dan RR dalam rentang normal</span></div>
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Tidak ada perubahan warna kulit dan tidak ada
pusing</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 30.06%;" valign="top" width="30%">
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>NIC :</b></span></div>
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;">
Fever
treatment</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor suhu sesering mungkin</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor IWL</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor warna dan suhu kulit</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor tekanan darah, nadi dan RR</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor penurunan tingkat kesadaran</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor WBC, Hb, dan Hct</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor intake dan output</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Kolaborasikan pemberian anti piretik</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan pengobatan untuk mengatasi penyebab demam</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Selimuti pasien</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Lakukan tapid sponge</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan cairan intravena</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Kompres pasien pada lipat paha dan aksila</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Tingkatkan sirkulasi udara</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan
pengobatan untuk mencegah terjadinya menggigil</span></span></div>
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>Temperature
regulation</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor suhu minimal tiap 2 jam</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Rencanakan monitoring suhu secara kontinyu</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor TD, nadi, dan RR</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor warna dan suhu kulit</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor tanda-tanda hipertermi dan hipotermi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Tingkatkan intake cairan dan nutrisi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Selimuti pasien untuk mencegah hilangnya kehangatan tubuh</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Ajarkan pada pasien cara mencegah keletihan akibat panas</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Diskusikan tentang pentingnya pengaturan suhu dan kemungkinan efek
negatif dari kedinginan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Beritahukan tentang indikasi terjadinya keletihan dan penanganan
emergency yang diperlukan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span lang="IT"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="IT">Ajarkan indikasi dari
hipotermi dan penanganan yang diperlukan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Berikan anti piretik jika
perlu</span></span></div>
<div class="MsoNormal" style="margin-left: 7.45pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>Vital
sign Monitoring</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Monitor TD, nadi, suhu, dan
RR</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Catat adanya fluktuasi tekanan darah</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Monitor VS saat pasien
berbaring, duduk, atau berdiri</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Auskultasi TD pada kedua
lengan dan bandingkan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor TD, nadi, RR, sebelum, selama, dan setelah aktivitas</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor kualitas dari nadi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor frekuensi dan irama pernapasan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor suara paru</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor pola pernapasan abnormal</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Monitor suhu, warna, dan
kelembaban kulit</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor sianosis perifer</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Monitor adanya cushing triad
(tekanan nadi yang melebar, bradikardi, peningkatan sistolik)</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="IT">Identifikasi penyebab dari perubahan vital sign</span><span lang="IT"></span></span></div>
<div class="MsoNormal" style="margin-left: 3.65pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
2</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 37.42%;" valign="top" width="37%">
<div class="MsoNormal" style="line-height: 150%;">
<span style="font-size: small;"><span style="line-height: 150%;">Resiko injury b/d infeksi mikroorganisme</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 27.32%;" valign="top" width="27%">
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NOC</b>
: Risk Kontrol</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 20.75pt; text-align: justify; text-indent: -11.75pt;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Klien
terbebas dari cedera</span></div>
<div class="MsoNormal" style="margin-left: 20.75pt; text-align: justify; text-indent: -11.75pt;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Klien
mampu menjelaskan cara/metode untukmencegah injury/cedera</span></div>
<div class="MsoNormal" style="margin-left: 20.75pt; text-align: justify; text-indent: -11.75pt;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Klien
mampu menjelaskan factor resiko dari lingkungan/perilaku personal</span></div>
<div class="MsoNormal" style="margin-left: 20.75pt; text-align: justify; text-indent: -11.75pt;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Mampumemodifikasi
gaya hidup untukmencegah injury</span></div>
<div class="MsoNormal" style="margin-left: 20.75pt; text-align: justify; text-indent: -11.75pt;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Menggunakan
fasilitas kesehatan yang ada</span></div>
<div class="MsoNormal" style="margin-left: 20.75pt; text-align: justify; text-indent: -11.75pt;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Mampu
mengenali perubahan status kesehatan </span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 30.06%;" valign="top" width="30%">
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NIC</b>
: <b>Environment Management (Manajemen lingkungan)</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Sediakan lingkungan yang
aman untuk pasien</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Identifikasi kebutuhan
keamanan pasien, sesuai dengan kondisi fisik dan fungsi kognitif<span> </span>pasien dan riwayat penyakit terdahulu
pasien</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Menghindarkan lingkungan
yang berbahaya (misalnya memindahkan perabotan)</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Memasang side rail tempat tidur</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Menyediakan tempat tidur
yang nyaman dan bersih</span></span></div>
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<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Menempatkan saklar lampu
ditempat yang mudah dijangkau pasien.</span></span></div>
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<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Membatasi pengunjung</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Memberikan penerangan yang cukup</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Menganjurkan keluarga untuk
menemani pasien.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Mengontrol lingkungan dari kebisingan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Memindahkan barang-barang yang dapat membahayakan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan penjelasan pada pasien dan keluarga atau pengunjung adanya
perubahan status kesehatan dan penyebab penyakit.</span><span></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
3</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 37.42%;" valign="top" width="37%">
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-size: small;"><span style="line-height: 150%;">Resiko defisit volume cairan b/d intake
yang kurang dan diaporesis</span></span></div>
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<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : Penurunan cairan intravaskuler,
interstisial, dan/atau intrasellular. Ini mengarah ke dehidrasi, kehilangan
cairan dengan pengeluaran sodium</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span>Batasan
Karakteristik : </span></span></div>
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<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Kelemahan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Haus </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Penurunan turgor kulit/lidah </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Membran mukosa/kulit kering </span></span></div>
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<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Peningkatan denyut nadi, penurunan tekanan darah,
penurunan volume/tekanan nadi </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Pengisian vena menurun </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perubahan status mental</span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Konsentrasi urine meningkat </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Temperatur tubuh meningkat </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Hematokrit meninggi </span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Kehilangan berat badan seketika (kecuali pada third spacing)</span><span></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Faktor-faktor yang berhubungan: </span></span></div>
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<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Kehilangan volume cairan secara aktif </span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Kegagalan mekanisme pengaturan</span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 27.32%;" valign="top" width="27%">
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NOC: </b></span></div>
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<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Fluid
balance</span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Hydration</span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Nutritional
Status : Food and Fluid Intake</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Mempertahankan
urine output sesuai dengan usia dan BB, BJ urine normal, HT normal</span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Tekanan
darah, nadi, suhu tubuh dalam batas normal</span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Tidak
ada tanda tanda dehidrasi, Elastisitas turgor kulit baik, membran mukosa
lembab, tidak ada rasa haus yang berlebihan</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 30.06%;" valign="top" width="30%">
<div class="MsoHeading9">
<span style="font-size: small;">
Fluid management</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Timbang popok/pembalut jika diperlukan </span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Pertahankan catatan intake dan output yang akurat</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Monitor status hidrasi ( kelembaban membran mukosa,
nadi adekuat, tekanan darah ortostatik ), jika diperlukan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Monitor vital sign</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Monitor masukan makanan / cairan dan hitung intake
kalori harian</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Lakukan terapi IV </span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Monitor status nutrisi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Berikan cairan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Berikan cairan IV pada suhu ruangan </span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Dorong masukan oral</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Berikan penggantian nesogatrik sesuai output</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Dorong keluarga untuk membantu pasien makan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Tawarkan snack ( jus
buah, buah segar )</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="IT"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="IT">Kolaborasi dokter jika tanda cairan berlebih muncul
meburuk </span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Atur kemungkinan tranfusi</span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Persiapan untuk tranfusi</span></span></div>
<div class="MsoNormal">
</div>
</td></tr>
</tbody></table>
ERFANSYAH. HRhttp://www.blogger.com/profile/07497970584312798191noreply@blogger.com0tag:blogger.com,1999:blog-2228299828902052163.post-63377785696757086942012-11-20T20:35:00.002-08:002013-03-11T10:03:24.328-07:00Asuhan Keperawatan Diare Menggunakan NANDA, NIC, NOC<h3 class="post-title entry-title" itemprop="name" style="font-family: "Courier New",Courier,monospace;">
<span style="font-size: small;">
Asuhan Keperawatan Diare Menggunakan NANDA, NIC, NOC
</span></h3>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span><br style="font-family: "Courier New",Courier,monospace;" /><span style="font-family: "Courier New",Courier,monospace;">
</span></span>
<h3 style="font-family: "Courier New",Courier,monospace;">
<span style="font-size: small;"><span><span>A.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span>Masalah
Yang lazim muncul pada klien</span></h3>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>1.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="line-height: 150%;">Defisit volume cairan b/d kehilangan cairan aktif</span></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>2.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="line-height: 150%;">Risiko kerusakan integritas kulit b/d ekskresi/BAB sering</span></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>3.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="line-height: 150%;">Ketidakseimbangan nutrisi kurang dari kebutuhan tubuh b/d
penurunan intake makanan</span></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>4.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="line-height: 150%;">Cemas b/d perubahan status kesehatan</span></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; line-height: 150%;">
<span style="font-size: small;"><br /></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><h3 style="font-family: "Courier New",Courier,monospace;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>B.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span style="line-height: 150%;">Discharge
Planning</span></span></h3>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoBodyTextIndent3" style="font-family: "Courier New",Courier,monospace; line-height: 150%; margin: 0in 0in 0in 63pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL" style="line-height: 150%;"><span>1.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL" style="line-height: 150%;">Ajarkan pada orang tua mengenai perawatan anak, pemberian
makanan dan minuman (missal oralit).</span></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoBodyTextIndent3" style="font-family: "Courier New",Courier,monospace; line-height: 150%; margin: 0in 0in 0in 63pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL" style="line-height: 150%;"><span>2.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL" style="line-height: 150%;">Ajarkan mengenai tanda tanda dehidrasi, ubun ubundan mata
cekung, turgor kulit tidak elastis, membran mukosa kering</span></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoBodyTextIndent3" style="font-family: "Courier New",Courier,monospace; line-height: 150%; margin: 0in 0in 0in 63pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL" style="line-height: 150%;"><span>3.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL" style="line-height: 150%;">Jelaskan obat obatan yang diberikan, efek samping dan
kegunaannya.</span></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoBodyTextIndent3" style="font-family: "Courier New",Courier,monospace; line-height: 150%; margin: 0in 0in 0in 63pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: medium none; font-family: "Courier New",Courier,monospace; width: 100%;">
<tbody>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>No</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 28.88%;" valign="top" width="28%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>Diagnosa
keperawatan</span></span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 32.52%;" valign="top" width="32%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>Tujuan
dan Kriteria Hasil</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 33.4%;" valign="top" width="33%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>Intervensi</span></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
1</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 28.88%;" valign="top" width="28%">
<div class="MsoNormal">
<span style="font-size: small;">
Defisit volume cairan b/d kehilangan cairan aktif</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : Penurunan cairan intravaskuler, interstisial,
dan/atau intrasellular. Ini mengarah ke dehidrasi, kehilangan cairan dengan
pengeluaran sodium</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span>Batasan
Karakteristik : </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Kelemahan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Haus </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Penurunan turgor kulit/lidah </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Membran mukosa/kulit kering </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Peningkatan denyut nadi, penurunan tekanan
darah, penurunan volume/tekanan nadi </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Pengisian vena menurun </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perubahan status mental</span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Konsentrasi urine meningkat </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Temperatur tubuh meningkat </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Hematokrit meninggi </span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Kehilangan berat badan seketika (kecuali pada third spacing)</span><span></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Faktor-faktor yang berhubungan: </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Kehilangan volume cairan secara aktif </span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Kegagalan mekanisme pengaturan</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 32.52%;" valign="top" width="32%">
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NOC: </b></span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Fluid
balance</span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Hydration</span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Nutritional
Status : Food and Fluid Intake</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Mempertahankan
urine output sesuai dengan usia dan BB, BJ urine normal, HT normal</span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Tekanan
darah, nadi, suhu tubuh dalam batas normal</span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Tidak
ada tanda tanda dehidrasi, Elastisitas turgor kulit baik, membran mukosa
lembab, tidak ada rasa haus yang berlebihan</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 33.4%;" valign="top" width="33%">
<div class="MsoBodyTextIndent" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>NIC :</b></span></div>
<div class="MsoHeading9">
<span style="font-size: small;">
Fluid management</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Timbang popok/pembalut jika diperlukan </span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Pertahankan catatan intake dan output yang akurat</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Monitor status hidrasi ( kelembaban membran mukosa,
nadi adekuat, tekanan darah ortostatik ), jika diperlukan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Monitor vital sign</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Monitor masukan makanan / cairan dan hitung intake
kalori harian</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Kolaborasikan pemberian cairan intravena IV </span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Monitor status nutrisi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Dorong masukan oral</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Berikan penggantian nesogatrik sesuai output</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Dorong keluarga untuk membantu pasien makan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Tawarkan snack ( jus
buah, buah segar )</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="IT"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="IT">Kolaborasi dokter jika tanda cairan berlebih muncul
meburuk </span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Atur kemungkinan tranfusi</span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Persiapan untuk tranfusi</span></span></div>
<div class="MsoNormal" style="margin-left: 3.55pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoBodyTextIndent" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>Hypovolemia
Management</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor status cairan termasuk intake dan ourput
cairan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Pelihara IV line</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor tingkat Hb dan hematokrit</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor tanda vital</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor responpasien terhadap penambahan cairan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor berat badan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Dorong pasien untuk menambah intake oral</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Pemberian cairan Iv monitor adanya tanda dan
gejala kelebihanvolume cairan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Monitor
adanya tanda gagal ginjal</span></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
2</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 28.88%;" valign="top" width="28%">
<div class="MsoNormal">
<span style="font-size: small;">
Risiko kerusakan
integritas kulit b/d ekskresi/BAB sering</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : Perubahan
pada epidermis dan dermis</span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Batasan karakteristik : </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Gangguan pada bagian tubuh </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kerusakan lapisa kulit (dermis) </span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Gangguan permukaan kulit (epidermis)</span><span></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Faktor yang berhubungan : </span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Eksternal : </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Hipertermia atau hipotermia </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Substansi kimia </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kelembaban udara </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Faktor mekanik (misalnya : alat yang dapat
menimbulkan luka, tekanan, restraint)</span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Immobilitas fisik </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Radiasi </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Usia yang ekstrim </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kelembaban kulit </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Obat-obatan </span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Internal : </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perubahan status metabolik </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Tulang menonjol </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Defisit imunologi </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Faktor yang berhubungan dengan perkembangan </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perubahan sensasi </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perubahan status nutrisi (obesitas,
kekurusan) </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perubahan status cairan </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perubahan pigmentasi </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Perubahan sirkulasi </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Perubahan turgor (elastisitas kulit)</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 32.52%;" valign="top" width="32%">
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NOC </b>:
Tissue Integrity : Skin and Mucous Membranes</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 39.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Integritas kulit yang baik bisa dipertahankan (sensasi, elastisitas,
temperatur, hidrasi, pigmentasi)</span></div>
<div class="MsoNormal" style="margin-left: 39.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Tidak ada luka/lesi pada kulit</span></div>
<div class="MsoNormal" style="margin-left: 39.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Perfusi
jaringan baik</span></div>
<div class="MsoNormal" style="margin-left: 39.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Menunjukkan
pemahaman dalam proses perbaikan kulit dan mencegah terjadinya sedera
berulang</span></div>
<div class="MsoNormal" style="margin-left: 39.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Mampu melindungi kulit dan mempertahankan kelembaban kulit dan perawatan
alami</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 33.4%;" valign="top" width="33%">
<div class="MsoNormal">
<span style="font-size: small;"><b>NIC </b>: <b>Pressure Management</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Anjurkan pasien untuk
menggunakan pakaian yang longgar</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Hindari kerutan padaa tempat tidur</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Jaga kebersihan kulit agar
tetap bersih dan kering</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Mobilisasi pasien (ubah
posisi pasien) setiap dua jam sekali</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor kulit akan adanya kemerahan </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Oleskan lotion atau minyak/baby oil pada derah yang tertekan </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor aktivitas dan mobilisasi pasien</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Monitor status
nutrisi pasien</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NL">Memandikan pasien dengan
sabun dan air hangat</span><span lang="NL"></span></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
3</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 28.88%;" valign="top" width="28%">
<div class="MsoNormal">
<span style="font-size: small;">
Ketidakseimbangan
nutrisi kurang dari kebutuhan tubuh b/d penurunan intake makanan</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : Intake nutrisi tidak cukup untuk
keperluan metabolisme tubuh.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Batasan karakteristik : </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Berat badan 20 % atau lebih di bawah ideal </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Dilaporkan adanya intake makanan yang kurang dari RDA (Recomended
Daily Allowance) </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Membran mukosa dan konjungtiva pucat </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Kelemahan otot yang digunakan untuk menelan/mengunyah </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Luka, inflamasi pada rongga mulut </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Mudah merasa kenyang, sesaat setelah mengunyah makanan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Dilaporkan atau fakta adanya kekurangan makanan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Dilaporkan adanya perubahan sensasi rasa </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perasaan ketidakmampuan untuk mengunyah
makanan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Miskonsepsi </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kehilangan BB dengan makanan cukup </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Keengganan untuk makan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kram pada abdomen </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Tonus otot jelek </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Nyeri abdominal dengan atau tanpa patologi </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kurang berminat terhadap makanan</span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Pembuluh darah kapiler mulai rapuh </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Diare dan atau steatorrhea </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kehilangan rambut yang cukup banyak (rontok) </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Suara usus hiperaktif</span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Kurangnya informasi, misinformasi</span><span></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Faktor-faktor yang berhubungan : </span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Ketidakmampuan pemasukan
atau mencerna makanan atau mengabsorpsi zat-zat gizi berhubungan dengan
faktor biologis, psikologis atau ekonomi.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 32.52%;" valign="top" width="32%">
<div class="MsoNormal">
<span style="font-size: small;"><b>NOC :</b></span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Nutritional
Status : </span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Nutritional
Status : food and Fluid Intake</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Nutritional
Status : nutrient Intake</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Weight
control</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><b>Kriteria
Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Adanya
peningkatan berat badan sesuai dengan tujuan</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Beratbadan
ideal sesuai dengan tinggi badan</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Mampumengidentifikasi
kebutuhan nutrisi</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Tidk
ada tanda tanda malnutrisi</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Menunjukkan
peningkatan fungsi pengecapan dari menelan</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Tidak
terjadi penurunan berat badan yang berarti</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 33.4%;" valign="top" width="33%">
<div class="MsoNormal">
<span style="font-size: small;"><b>Nutrition
Management</b></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Kaji adanya alergi makanan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Kolaborasi dengan ahli gizi untuk menentukan jumlah kalori dan nutrisi
yang dibutuhkan pasien.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Anjurkan pasien untuk meningkatkan intake Fe</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Anjurkan pasien untuk meningkatkan protein dan vitamin C</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan substansi gula</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Yakinkan diet yang dimakan mengandung tinggi serat untuk mencegah
konstipasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan makanan yang terpilih ( sudah dikonsultasikan dengan ahli
gizi)</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Ajarkan pasien bagaimana membuat catatan makanan harian.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor jumlah nutrisi dan kandungan kalori</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan informasi tentang kebutuhan nutrisi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Kaji kemampuan pasien untuk mendapatkan nutrisi yang dibutuhkan</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><b>Nutrition
Monitoring</b></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>BB pasien dalam batas normal</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor adanya penurunan berat badan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor tipe dan jumlah aktivitas yang biasa dilakukan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor interaksi anak atau orangtua selama makan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor lingkungan selama makan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Jadwalkan pengobatan<span> </span>dan
tindakan tidak selama jam makan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor kulit kering dan perubahan pigmentasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor turgor kulit</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor kekeringan, rambut kusam, dan mudah patah</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor mual dan muntah</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor kadar albumin, total protein, Hb, dan kadar Ht</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor makanan kesukaan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor pertumbuhan dan perkembangan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor pucat, kemerahan, dan kekeringan jaringan konjungtiva</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor kalori dan intake nuntrisi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Catat adanya edema,
hiperemik, hipertonik papila lidah dan cavitas oral.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Catat jika lidah
berwarna magenta, scarlet</span></span></div>
<div class="MsoNormal" style="margin-left: 3.55pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
4</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 28.88%;" valign="top" width="28%">
<div class="MsoNormal">
<span style="font-size: small;">
Cemas b/d perubahan status kesehatan</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : </span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><span lang="NO-BOK">Perasaan gelisah yang
tak jelas dari ketidaknyamanan atau ketakutan yang disertai respon autonom
(sumner tidak spesifik atau tidak diketahui oleh individu); perasaan
keprihatinan disebabkan dari antisipasi terhadap bahaya. Sinyal ini merupakan
peringatan adanya ancaman yang akan datang dan memungkinkan individu untuk
mengambil langkah untuk menyetujui terhadap tindakan</span><span></span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><span>Ditandai
dengan</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Gelisah</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Insomnia</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Resah</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Ketakutan</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Sedih</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Fokus pada diri</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Kekhawatiran</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Cemas</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 32.52%;" valign="top" width="32%">
<div class="MsoNormal">
<span style="font-size: small;"><b>NOC :</b></span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Anxiety
control</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Coping</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Impulse
control</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><b>Kriteria
Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Klien
mampu mengidentifikasi dan mengungkapkan gejala cemas</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Mengidentifikasi,
mengungkapkan dan menunjukkan tehnik untuk mengontol cemas</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Vital
sign dalam batas normal</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Postur
tubuh, ekspresi wajah, bahasa tubuh dan tingkat aktivitas menunjukkan
berkurangnya kecemasan</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 33.4%;" valign="top" width="33%">
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>NIC :</b></span></div>
<div class="MsoHeading7" style="line-height: normal;">
<span style="font-size: small;">
Anxiety
Reduction (penurunan kecemasan)</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Gunakan pendekatan yang menenangkan </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Nyatakan dengan jelas harapan terhadap pelaku pasien</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Jelaskan semua prosedur dan apa yang dirasakan selama
prosedur</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Pahami prespektif pasien terhdap situasi stres</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Temani pasien untuk memberikan keamanan dan mengurangi
takut</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Berikan informasi faktual mengenai diagnosis, tindakan
prognosis </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Dorong keluarga untuk menemani anak</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Lakukan back / neck rub</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Dengarkan dengan penuh perhatian</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Identifikasi tingkat kecemasan </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Bantu pasien mengenal situasi yang menimbulkan
kecemasan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Dorong pasien untuk mengungkapkan perasaan, ketakutan,
persepsi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Instruksikan pasien menggunakan teknik relaksasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Barikan obat untuk mengurangi kecemasan</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
</tr>
</tbody></table>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span>
ERFANSYAH. HRhttp://www.blogger.com/profile/07497970584312798191noreply@blogger.com0tag:blogger.com,1999:blog-2228299828902052163.post-84110309902119704872012-11-20T20:34:00.004-08:002013-03-11T10:03:24.345-07:00Asuhan Keperawatan AIDS Aplikasi NANDA, NIC, NOC <h3 class="post-title entry-title" itemprop="name" style="font-family: Georgia,"Times New Roman",serif;">
<span style="font-size: small;">
Asuhan Keperawatan AIDS Aplikasi NANDA, NIC, NOC </span></h3>
<h3 class="post-title entry-title" itemprop="name" style="font-family: Georgia,"Times New Roman",serif;">
<span style="font-size: small;"> </span></h3>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span><span style="font-family: Georgia,"Times New Roman",serif;">
</span><b style="font-family: Georgia,"Times New Roman",serif;"><span style="line-height: 150%;"></span></b></span>
<h3 style="font-family: Georgia,"Times New Roman",serif;">
<span style="font-size: small;"><span><span>A.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span>Masalah
Yang lazim muncul pada klien</span></h3>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>1.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="line-height: 150%;">Kelelahan b/d status penyakit, anemia, malnutrisi</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>2.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="line-height: 150%;">Nyeri akut/kronis b/d infeksi, nyeri abdomen</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>3.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="line-height: 150%;">Ketidakseimbangan nutrisi kurang dari kebutuhan tubuh b/d
gangguan pencernaan</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>4.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="line-height: 150%;">Diare b/d proses
pemyakit</span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%;">
<span style="font-size: small;"><br /></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><h3 style="font-family: Georgia,"Times New Roman",serif;">
<span style="font-size: small;"><span><span>B.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span>Discharge
Planning</span></h3>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 63pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>1.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Ajarkan pada anak dan keluarga
untuk menghubungi tim kesehatan bila terdapat tanda tanda atau gejala infeksi</span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 63pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>2.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Ajarkan
pada anak dan keluarga<span> </span>untuk mengamati
respon terhadap pengobatan dan memberitahu dokter tentangadanya efek samping</span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; margin-left: 63pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>3.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span>Ajarkan
pada anak dan keluarga tentang penjadwalan pemeriksaan lebih lanjut.<span lang="NL"></span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Georgia,"Times New Roman",serif; line-height: 150%; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span>
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: medium none; font-family: Georgia,"Times New Roman",serif; width: 100%;"><tbody>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>No</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 28.88%;" valign="top" width="28%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>Diagnosa
keperawatan</span></span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 32.52%;" valign="top" width="32%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>Tujuan
dan Kriteria Hasil</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 33.4%;" valign="top" width="33%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>Intervensi</span></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
1</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 28.88%;" valign="top" width="28%">
<div class="MsoBodyText3" style="line-height: 150%;">
<span style="font-size: small;">
Kelelahan b/d status penyakit,
anemia, malnutrisi</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 32.52%;" valign="top" width="32%">
<div class="MsoNormal">
<span style="font-size: small;"><b>NOC :</b></span></div>
<div class="MsoNormal" style="margin-left: 20.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Endurance</span></div>
<div class="MsoNormal" style="margin-left: 20.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Concentration</span></div>
<div class="MsoNormal" style="margin-left: 20.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Energy
conservation</span></div>
<div class="MsoNormal" style="margin-left: 20.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Nutritional
status : energy</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><b>Kriteria
Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 20.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Memverbalisasikan peningkatan energi dan merasa lebih baik</span></div>
<div class="MsoNormal" style="margin-left: 20.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Menjelaskan penggunaan energi untuk mengatasi kelelahan</span></div>
<div class="MsoBodyTextIndent2" style="line-height: normal;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 33.4%;" valign="top" width="33%">
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>NIC :</b></span></div>
<div class="MsoHeading7" style="line-height: normal;">
<span style="font-size: small;">
Energy
Management<span> </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Observasi
adanya pembatasan klien dalam melakukan aktivitas</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Dorong anal untuk mengungkapkan perasaan terhadap keterbatasan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Kaji
adanya factor yang menyebabkan kelelahan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Monitor nutrisi<span> </span>dan sumber energi
tangadekuat</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Monitor pasien akan adanya kelelahan fisik dan emosi secara berlebihan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Monitor
respon kardivaskuler<span> </span>terhadap
aktivitas</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="IT">Monitor pola tidur dan lamanya tidur/istirahat pasien</span></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
2</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 28.88%;" valign="top" width="28%">
<div class="MsoNormal">
<span style="font-size: small;"><span>Nyeri akut/kronis b/d infeksi, nyeri
abdomen</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : </span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Sensori yang tidak menyenangkan dan pengalaman
emosional yang muncul secara aktual atau potensial kerusakan jaringan atau
menggambarkan adanya kerusakan (Asosiasi Studi Nyeri Internasional): serangan
mendadak atau pelan intensitasnya dari ringan sampai berat yang dapat
diantisipasi dengan akhir yang dapat diprediksi dan dengan durasi kurang dari
6 bulan.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Batasan karakteristik : </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Laporan secara verbal atau non verbal </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Fakta dari observasi </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Posisi antalgic untuk menghindari nyeri </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Gerakan melindungi </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Tingkah laku berhati-hati</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Muka topeng </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Gangguan tidur (mata sayu, tampak capek,
sulit atau gerakan kacau, menyeringai)</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Terfokus pada diri sendiri </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Fokus menyempit (penurunan persepsi waktu, kerusakan
proses berpikir, penurunan interaksi dengan orang dan lingkungan) </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Tingkah laku distraksi, contoh : jalan-jalan,
menemui orang lain dan/atau aktivitas, aktivitas berulang-ulang)</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Respon autonom (seperti diaphoresis,
perubahan tekanan darah, perubahan nafas, nadi dan dilatasi pupil)</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perubahan autonomic dalam tonus otot (mungkin
dalam rentang dari lemah ke kaku) </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Tingkah laku ekspresif (contoh : gelisah,
merintih, menangis, waspada, iritabel, nafas panjang/berkeluh kesah) </span><span lang="NO-BOK"></span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perubahan dalam nafsu makan dan minum</span><span lang="NL"></span></span></div>
<div class="MsoNormal" style="margin-left: 2.1pt;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Faktor yang berhubungan : </span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Agen injuri (biologi, kimia, fisik, psikologis)</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 32.52%;" valign="top" width="32%">
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NOC : </b></span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Pain Level,</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Pain control,</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Comfort level</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Mampu
mengontrol nyeri (tahu penyebab nyeri, mampu menggunakan tehnik
nonfarmakologi untuk mengurangi nyeri, mencari bantuan)</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Melaporkan bahwa nyeri berkurang dengan menggunakan manajemen nyeri</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Mampu mengenali nyeri (skala, intensitas, frekuensi dan tanda nyeri)</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Menyatakan rasa nyaman setelah nyeri berkurang</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Tanda
vital dalam rentang normal</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 33.4%;" valign="top" width="33%">
<h1>
<span style="font-size: small;">
Pain Management</span></h1>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Lakukan pengkajian nyeri secara komprehensif termasuk lokasi,
karakteristik, durasi, frekuensi, kualitas dan faktor presipitasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Observasi reaksi nonverbal dari ketidaknyamanan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Gunakan teknik komunikasi terapeutik untuk mengetahui pengalaman nyeri
pasien</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Kaji kultur yang mempengaruhi respon nyeri</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Evaluasi pengalaman nyeri masa lampau</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Evaluasi bersama pasien dan tim kesehatan lain tentang
ketidakefektifan kontrol nyeri masa lampau</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Bantu pasien dan keluarga
untuk mencari dan menemukan dukungan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Kontrol lingkungan yang
dapat mempengaruhi nyeri seperti suhu ruangan, pencahayaan dan kebisingan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Kurangi faktor presipitasi nyeri</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="IT"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="IT">Pilih dan lakukan penanganan
nyeri (farmakologi, non farmakologi dan inter personal)</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Kaji tipe dan sumber nyeri
untuk menentukan intervensi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Ajarkan tentang teknik non farmakologi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan analgetik untuk mengurangi nyeri</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Evaluasi keefektifan kontrol nyeri</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Tingkatkan istirahat</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Kolaborasikan dengan dokter
jika ada keluhan dan tindakan nyeri tidak berhasil</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Monitor penerimaan pasien tentang manajemen nyeri</span><b><span lang="NL"></span></b></span></div>
<div class="MsoNormal" style="margin-left: 3.55pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Analgesic Administration</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Tentukan lokasi,
karakteristik, kualitas, dan derajat nyeri sebelum pemberian obat</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Cek instruksi dokter tentang
jenis obat, dosis, dan frekuensi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Cek riwayat alergi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Pilih analgesik yang diperlukan atau kombinasi dari analgesik ketika
pemberian lebih dari satu </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Tentukan pilihan analgesik
tergantung tipe dan beratnya nyeri</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Tentukan analgesik pilihan,
rute pemberian, dan dosis optimal</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="IT"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="IT">Pilih rute pemberian secara
IV, IM untuk pengobatan nyeri secara teratur</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor vital sign sebelum dan sesudah pemberian analgesik pertama
kali</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Berikan analgesik tepat
waktu terutama saat nyeri hebat</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Evaluasi efektivitas analgesik, tanda dan gejala (efek samping)</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
3</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 28.88%;" valign="top" width="28%">
<div class="MsoBodyText3" style="line-height: 150%;">
<span style="font-size: small;">
Ketidakseimbangan nutrisi
kurang dari kebutuhan tubuh b/d gangguan pencernaan</span></div>
<div class="MsoBodyText3" style="line-height: 150%;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : Intake nutrisi tidak cukup untuk
keperluan metabolisme tubuh.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Batasan karakteristik : </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Berat badan 20 % atau lebih di bawah ideal </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Dilaporkan adanya intake makanan yang kurang
dari RDA (Recomended Daily Allowance) </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Membran mukosa dan konjungtiva pucat </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kelemahan otot yang digunakan untuk
menelan/mengunyah </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Luka, inflamasi pada rongga mulut </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Mudah merasa kenyang, sesaat setelah
mengunyah makanan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Dilaporkan atau fakta adanya kekurangan
makanan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Dilaporkan adanya perubahan sensasi rasa </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perasaan ketidakmampuan untuk mengunyah
makanan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Miskonsepsi </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kehilangan BB dengan makanan cukup </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Keengganan untuk makan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kram pada abdomen </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Tonus otot jelek </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Nyeri abdominal dengan atau tanpa patologi </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kurang berminat terhadap makanan</span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Pembuluh darah kapiler mulai rapuh </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Diare dan atau steatorrhea </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kehilangan rambut yang cukup banyak (rontok) </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Suara usus hiperaktif</span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Kurangnya informasi, misinformasi</span><span></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Faktor-faktor yang berhubungan : </span></span></div>
<div class="MsoBodyText3" style="line-height: 150%;">
<span style="font-size: small;"><span lang="NO-BOK" style="line-height: 150%;">Ketidakmampuan pemasukan atau mencerna makanan atau
mengabsorpsi zat-zat gizi berhubungan dengan faktor biologis, psikologis atau
ekonomi.</span></span></div>
<div class="MsoBodyText3" style="line-height: 150%;">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 32.52%;" valign="top" width="32%">
<div class="MsoNormal">
<span style="font-size: small;"><b>NOC :</b></span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Nutritional
Status : </span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Nutritional
Status : food and Fluid Intake</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Nutritional
Status : nutrient Intake</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Weight
control</span></div>
<div class="MsoNormal" style="margin-left: 11.75pt;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><b>Kriteria
Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Adanya
peningkatan berat badan sesuai dengan tujuan</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Beratbadan
ideal sesuai dengan tinggi badan</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Mampumengidentifikasi
kebutuhan nutrisi</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Tidk
ada tanda tanda malnutrisi</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Menunjukkan
peningkatan fungsi pengecapan dari menelan</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Tidak terjadi penurunan berat badan yang berarti</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 33.4%;" valign="top" width="33%">
<div class="MsoNormal">
<span style="font-size: small;"><b>Nutrition
Management</b></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Kaji adanya alergi makanan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Kolaborasi dengan ahli gizi untuk menentukan jumlah kalori dan nutrisi
yang dibutuhkan pasien.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Anjurkan pasien untuk
meningkatkan intake Fe</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Anjurkan pasien untuk
meningkatkan protein dan vitamin C</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan substansi gula</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Yakinkan diet yang dimakan
mengandung tinggi serat untuk mencegah konstipasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Berikan makanan yang
terpilih ( sudah dikonsultasikan dengan ahli gizi)</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Ajarkan pasien bagaimana membuat catatan makanan harian.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Monitor jumlah nutrisi dan
kandungan kalori</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan informasi tentang kebutuhan nutrisi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Kaji kemampuan pasien untuk mendapatkan nutrisi yang dibutuhkan</span></span></div>
<div class="MsoNormal" style="margin-left: 3.55pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><b>Nutrition
Monitoring</b></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>BB pasien dalam batas normal</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor adanya penurunan berat badan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Monitor tipe dan jumlah
aktivitas yang biasa dilakukan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="IT"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="IT">Monitor interaksi anak atau
orangtua selama makan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor lingkungan selama makan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Jadwalkan pengobatan<span> </span>dan tindakan tidak selama jam makan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Monitor kulit kering dan
perubahan pigmentasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor turgor kulit</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Monitor kekeringan, rambut
kusam, dan mudah patah</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor mual dan muntah</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Monitor kadar albumin, total
protein, Hb, dan kadar Ht</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor makanan kesukaan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor pertumbuhan dan perkembangan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Monitor pucat, kemerahan,
dan kekeringan jaringan konjungtiva</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor kalori dan intake nuntrisi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Catat adanya edema,
hiperemik, hipertonik papila lidah dan cavitas oral.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="IT">Catat jika lidah berwarna
magenta, scarlet</span><span lang="IT"></span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><br /></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
4</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 28.88%;" valign="top" width="28%">
<div class="MsoNormal">
<span style="font-size: small;"><span>Diare b/d proses pemyakit</span><span></span></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 32.52%;" valign="top" width="32%">
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NOC: </b></span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Bowel
elimination</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Fluid
Balance</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Hydration</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Electrolyte
and Acid base Balance</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Feses
berbentuk, BAB sehari sekali- tiga hari</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Menjaga daerah sekitar rectal dari iritasi</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Tidak
mengalami diare</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Menjelaskan
penyebab diare dan rasional tendakan</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Mempertahankan
turgor kulit</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 33.4%;" valign="top" width="33%">
<div class="MsoBodyTextIndent" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>NIC :</b></span></div>
<div class="MsoBodyTextIndent" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>Diarhea
Management</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Evaluasi efek samping pengobatan terhadap
gastrointestinal</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Ajarkan pasien untuk menggunakan obat antidiare</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Instruksikan pasien/keluarga untukmencatat warna,
jumlah, frekuenai dan konsistensi dari feses</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Evaluasi intake makanan yang masuk</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Identifikasi factor penyebab dari diare</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor tanda dan gejala diare</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Observasi turgor kulit secara rutin</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Ukur diare/keluaran BAB</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Hubungi dokter jika ada kenanikan bising usus</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Instruksikan pasien untukmakan rendah serat,
tinggi protein dan tinggi kalori jika memungkinkan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Instruksikan untuk menghindari laksative</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Ajarkan
tehnik menurunkan stress</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Monitor
persiapan makanan yang aman</span></span></div>
</td></tr>
</tbody></table>
ERFANSYAH. HRhttp://www.blogger.com/profile/07497970584312798191noreply@blogger.com0tag:blogger.com,1999:blog-2228299828902052163.post-69634543438507510332012-11-20T20:33:00.001-08:002013-03-11T10:03:24.334-07:00Asuhan Keperawatan Vomitus Aplikasi NANDA, NIC, NOC<h3 class="post-title entry-title" itemprop="name" style="font-family: Times,"Times New Roman",serif;">
<span style="font-size: small;">
Asuhan Keperawatan Vomitus Aplikasi NANDA, NIC, NOC
</span></h3>
<span style="font-size: small;"><span style="font-family: Times,"Times New Roman",serif;">
</span></span><span style="font-size: small;"><span style="font-family: Times,"Times New Roman",serif;">
</span><br style="font-family: Times,"Times New Roman",serif;" /><span style="font-family: Times,"Times New Roman",serif;">
<span>A.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Masalah
Yang lazim muncul pada klien
</span></span>
<div class="MsoNormal" style="font-family: Times,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>1.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="line-height: 150%;">Defisit volume cairan b/d kehilangan cairan aktif</span></span></div>
<span style="font-size: small;"><span style="font-family: Times,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Times,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>2.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="line-height: 150%;">Ketidakseimbangn nutrisi kurang dari kebutuhan tubuh b/d
gangguan absorbsi</span></span></div>
<span style="font-size: small;"><span style="font-family: Times,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Times,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="IT" style="line-height: 150%;"><span>3.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="IT" style="line-height: 150%;">Ketidakefektifan perfusi jaringan b/d hipovolemia</span></span></div>
<span style="font-size: small;"><span style="font-family: Times,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Times,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;"><span>4.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="line-height: 150%;">Resiko kerusakan integritas kulit b/d gangguan status
metabolic</span></span></div>
<span style="font-size: small;"><span style="font-family: Times,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Times,"Times New Roman",serif; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span>5.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="line-height: 150%;">Cemas b/d perubahan status
kesehatan</span></span></div>
<span style="font-size: small;"><span style="font-family: Times,"Times New Roman",serif;">
</span></span><div class="MsoNormal" style="font-family: Times,"Times New Roman",serif; line-height: 150%; margin-left: 45pt;">
<span style="font-size: small;"><br /></span></div>
<span style="font-size: small;"><span style="font-family: Times,"Times New Roman",serif;">
</span></span>
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: medium none; font-family: Times,"Times New Roman",serif; width: 100%;"><tbody>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>No</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 27.42%;" valign="top" width="27%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>Diagnosa
keperawatan</span></span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 35.46%;" valign="top" width="35%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>Tujuan
dan Kriteria Hasil</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 31.92%;" valign="top" width="31%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>Intervensi</span></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
1</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 27.42%;" valign="top" width="27%">
<div class="MsoNormal">
<span style="font-size: small;"><span>Defisit volume cairan b/d kehilangan cairan
aktif</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : Penurunan cairan intravaskuler,
interstisial, dan/atau intrasellular. Ini mengarah ke dehidrasi, kehilangan
cairan dengan pengeluaran sodium</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span>Batasan
Karakteristik : </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Kelemahan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Haus </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Penurunan turgor kulit/lidah </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Membran mukosa/kulit kering </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Peningkatan denyut nadi, penurunan tekanan
darah, penurunan volume/tekanan nadi </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Pengisian vena menurun </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perubahan status mental</span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Konsentrasi urine meningkat </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Temperatur tubuh meningkat </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Hematokrit meninggi </span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Kehilangan berat badan seketika (kecuali pada third spacing)</span><span></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Faktor-faktor yang berhubungan: </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Kehilangan volume cairan secara aktif </span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Kegagalan mekanisme pengaturan</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 35.46%;" valign="top" width="35%">
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NOC: </b></span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Fluid
balance</span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Hydration</span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Nutritional
Status : Food and Fluid Intake</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Mempertahankan
urine output sesuai dengan usia dan BB, BJ urine normal, HT normal</span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Tekanan
darah, nadi, suhu tubuh dalam batas normal</span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Tidak
ada tanda tanda dehidrasi, Elastisitas turgor kulit baik, membran mukosa
lembab, tidak ada rasa haus yang berlebihan</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 31.92%;" valign="top" width="31%">
<div class="MsoHeading9">
<span style="font-size: small;">
Fluid management</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Timbang popok/pembalut jika diperlukan </span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Pertahankan catatan intake dan output yang akurat</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Monitor status hidrasi ( kelembaban membran mukosa,
nadi adekuat, tekanan darah ortostatik ), jika diperlukan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Monitor vital sign</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Monitor masukan makanan / cairan dan hitung intake
kalori harian</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Kolaborasikan pemberian cairan IV </span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Monitor status nutrisi </span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Dorong masukan oral</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Berikan penggantian nesogatrik sesuai output</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Dorong keluarga untuk membantu pasien makan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Tawarkan snack ( jus
buah, buah segar )</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="IT"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="IT">Kolaborasi dokter jika tanda cairan berlebih muncul
meburuk </span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Atur kemungkinan tranfusi</span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Persiapan untuk tranfusi</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
2</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 27.42%;" valign="top" width="27%">
<div class="MsoNormal">
<span style="font-size: small;"><span>Ketidakseimbangn nutrisi kurang dari
kebutuhan tubuh b/d gangguan absorbsi</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : Intake nutrisi tidak cukup untuk
keperluan metabolisme tubuh.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Batasan karakteristik : </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Berat badan 20 % atau lebih di bawah ideal </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Dilaporkan adanya intake makanan yang kurang
dari RDA (Recomended Daily Allowance) </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Membran mukosa dan konjungtiva pucat </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kelemahan otot yang digunakan untuk
menelan/mengunyah </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Luka, inflamasi pada rongga mulut </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Mudah merasa kenyang, sesaat setelah
mengunyah makanan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Dilaporkan atau fakta adanya kekurangan
makanan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Dilaporkan adanya perubahan sensasi rasa </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perasaan ketidakmampuan untuk mengunyah
makanan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Miskonsepsi </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kehilangan BB dengan makanan cukup </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Keengganan untuk makan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kram pada abdomen </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Tonus otot jelek </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Nyeri abdominal dengan atau tanpa patologi </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kurang berminat terhadap makanan</span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Pembuluh darah kapiler mulai rapuh </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Diare dan atau steatorrhea </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kehilangan rambut yang cukup banyak (rontok) </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Suara usus hiperaktif</span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NO-BOK">Kurangnya informasi, misinformasi</span><span></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Faktor-faktor yang berhubungan : </span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Ketidakmampuan pemasukan atau mencerna makanan atau
mengabsorpsi zat-zat gizi berhubungan dengan faktor biologis, psikologis atau
ekonomi.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 35.46%;" valign="top" width="35%">
<div class="MsoNormal">
<span style="font-size: small;"><b>NOC :</b></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Nutritional Status : food and
Fluid Intake</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><b>Kriteria
Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Adanya peningkatan berat
badan sesuai dengan tujuan</span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Berat badan ideal sesuai
dengan tinggi badan</span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Mampu mengidentifikasi
kebutuhan nutrisi</span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Tidak ada tanda tanda
malnutrisi</span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Tidak terjadi penurunan berat
badan yang berarti</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 31.92%;" valign="top" width="31%">
<div class="MsoNormal">
<span style="font-size: small;"><b>Nutrition
Management</b></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Kaji adanya alergi makanan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Kolaborasi dengan ahli gizi untuk menentukan jumlah kalori dan nutrisi
yang dibutuhkan pasien.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Anjurkan pasien untuk meningkatkan intake Fe</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Anjurkan pasien untuk meningkatkan protein dan vitamin C</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan substansi gula</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Yakinkan diet yang dimakan mengandung tinggi serat untuk mencegah
konstipasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan makanan yang terpilih ( sudah dikonsultasikan dengan ahli
gizi)</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Ajarkan pasien bagaimana membuat catatan makanan harian.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor jumlah nutrisi dan kandungan kalori</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Berikan informasi tentang kebutuhan nutrisi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Kaji kemampuan pasien untuk mendapatkan nutrisi yang dibutuhkan</span></span></div>
<div class="MsoNormal" style="margin-left: 3.55pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><b>Nutrition
Monitoring</b></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>BB pasien dalam batas normal</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor adanya penurunan berat badan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor tipe dan jumlah aktivitas yang biasa dilakukan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor interaksi anak atau orangtua selama makan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor lingkungan selama makan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Jadwalkan pengobatan<span> </span>dan
tindakan tidak selama jam makan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor kulit kering dan perubahan pigmentasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor turgor kulit</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor kekeringan, rambut kusam, dan mudah patah</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor mual dan muntah</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor kadar albumin, total protein, Hb, dan kadar Ht</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor makanan kesukaan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor pertumbuhan dan perkembangan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor pucat, kemerahan, dan kekeringan jaringan konjungtiva</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor kalori dan intake nuntrisi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Catat adanya edema,
hiperemik, hipertonik papila lidah dan cavitas oral.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Catat jika lidah
berwarna magenta, scarlet</span></span></div>
<div class="MsoNormal" style="margin-left: 3.55pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="margin-left: 3.55pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="margin-left: 3.55pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="margin-left: 3.55pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><br /></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
3</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 27.42%;" valign="top" width="27%">
<div class="MsoNormal">
<span style="font-size: small;"><span>Ketidakefektifan perfusi jaringan b/d
hipovolemia</span></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 35.46%;" valign="top" width="35%">
<div class="MsoNormal">
<span style="font-size: small;"><b>NOC :</b></span></div>
<div class="MsoNormal" style="margin-left: 29.75pt;">
<span style="font-size: small;">
Circulation status</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt;">
<span style="font-size: small;">
Tissue Prefusion : cerebral</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><b>Kriteria
Hasil :</b></span></div>
<div class="MsoNormal">
<span style="font-size: small;">
mendemonstrasikan status sirkulasi yang ditandai
dengan :</span></div>
<div class="MsoNormal" style="margin-left: 56.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Tekanan systole dandiastole
dalam rentang yang diharapkan</span></div>
<div class="MsoNormal" style="margin-left: 56.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Tidak ada
ortostatikhipertensi</span></div>
<div class="MsoNormal" style="margin-left: 56.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Tidk ada tanda tanda
peningkatan tekanan intrakranial (tidak lebih dari 15 mmHg)</span></div>
<div class="MsoNormal">
<span style="font-size: small;">
mendemonstrasikan kemampuan kognitif yang
ditandai dengan:</span></div>
<div class="MsoNormal" style="margin-left: 56.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>berkomunikasi dengan jelas
dan sesuai dengan kemampuan</span></div>
<div class="MsoNormal" style="margin-left: 56.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>menunjukkan perhatian,
konsentrasi dan orientasi</span></div>
<div class="MsoNormal" style="margin-left: 56.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>memproses informasi</span></div>
<div class="MsoNormal" style="margin-left: 56.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>membuat keputusan dengan
benar</span></div>
<div class="MsoNormal">
<span style="font-size: small;">
menunjukkan fungsi sensori motori cranial yang
utuh : tingkat kesadaran mambaik, tidak ada gerakan gerakan involunter</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 31.92%;" valign="top" width="31%">
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>NIC :</b></span></div>
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>Peripheral
Sensation Management (Manajemen sensasi perifer)</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Monitor adanya daerah
tertentu yang hanya peka terhadap panas/dingin/tajam/tumpul</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Monitor adanya paretese</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Instruksikan keluarga untuk
mengobservasi kulit jika ada lsi atau laserasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Gunakan sarun tangan untuk
proteksi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="IT">Batasi gerakan pada kepala, leher dan punggung</span><span lang="IT"></span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Monitor kemampuan BAB</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Kolaborasi pemberian
analgetik</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Monitor adanya tromboplebitis</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="IT">Diskusikan menganai penyebab perubahan</span><span lang="IT"> </span><span lang="IT">sensasi</span><span lang="IT"></span></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
4</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 27.42%;" valign="top" width="27%">
<div class="MsoNormal">
<span style="font-size: small;"><span>Resiko kerusakan integritas kulit b/d
gangguan status metabolic</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : Perubahan
pada epidermis dan dermis</span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Batasan karakteristik : </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Gangguan pada bagian tubuh </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kerusakan lapisa kulit (dermis) </span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Gangguan permukaan kulit (epidermis)</span><span></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Faktor yang berhubungan : </span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Eksternal : </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Hipertermia atau hipotermia </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Substansi kimia </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kelembaban udara </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Faktor mekanik (misalnya : alat yang dapat
menimbulkan luka, tekanan, restraint)</span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Immobilitas fisik </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Radiasi </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Usia yang ekstrim </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Kelembaban kulit </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Obat-obatan </span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Internal : </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perubahan status metabolik </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Tulang menonjol </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Defisit imunologi </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Faktor yang berhubungan dengan perkembangan </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perubahan sensasi </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perubahan status nutrisi (obesitas,
kekurusan) </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perubahan status cairan </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perubahan pigmentasi </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perubahan sirkulasi </span></span></div>
<div class="MsoNormal" style="margin-left: 20.05pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NO-BOK">Perubahan turgor (elastisitas kulit)</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 35.46%;" valign="top" width="35%">
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NOC </b>:
Tissue Integrity : Skin and Mucous Membranes</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 39.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Integritas kulit yang baik bisa dipertahankan (sensasi, elastisitas,
temperatur, hidrasi, pigmentasi)</span></div>
<div class="MsoNormal" style="margin-left: 39.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Tidak ada luka/lesi pada kulit</span></div>
<div class="MsoNormal" style="margin-left: 39.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Perfusi
jaringan baik</span></div>
<div class="MsoNormal" style="margin-left: 39.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Menunjukkan
pemahaman dalam proses perbaikan kulit dan mencegah terjadinya sedera
berulang</span></div>
<div class="MsoNormal" style="margin-left: 39.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Mampu melindungi kulit dan mempertahankan kelembaban kulit dan perawatan
alami</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 31.92%;" valign="top" width="31%">
<div class="MsoNormal">
<span style="font-size: small;"><b>NIC </b>: <b>Pressure Management</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Anjurkan pasien untuk
menggunakan pakaian yang longgar</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Hindari kerutan padaa tempat tidur</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Jaga kebersihan kulit agar
tetap bersih dan kering</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="NL">Mobilisasi pasien (ubah
posisi pasien) setiap dua jam sekali</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor kulit akan adanya kemerahan </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Oleskan lotion atau minyak/baby oil pada derah yang tertekan </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span>Monitor aktivitas dan mobilisasi pasien</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Monitor status
nutrisi pasien</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NL">Memandikan pasien dengan
sabun dan air hangat</span><span lang="NL"></span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><br /></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
5</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 27.42%;" valign="top" width="27%">
<div class="MsoNormal">
<span style="font-size: small;"><span>Cemas b/d perubahan status kesehatan</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : </span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><span lang="NO-BOK">Perasaan gelisah yang
tak jelas dari ketidaknyamanan atau ketakutan yang disertai respon autonom
(sumner tidak spesifik atau tidak diketahui oleh individu); perasaan
keprihatinan disebabkan dari antisipasi terhadap bahaya. Sinyal ini merupakan
peringatan adanya ancaman yang akan datang dan memungkinkan individu untuk
mengambil langkah untuk menyetujui terhadap tindakan</span><span lang="NO-BOK"></span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><span>Ditandai
dengan</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Gelisah</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Insomnia</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Resah</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Ketakutan</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Sedih</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Fokus pada diri</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Kekhawatiran</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span>Cemas</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 35.46%;" valign="top" width="35%">
<div class="MsoNormal">
<span style="font-size: small;"><b>NOC :</b></span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Anxiety
control</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Coping</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Impulse
control</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><b>Kriteria
Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Klien mampu mengidentifikasi dan mengungkapkan gejala cemas</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Mengidentifikasi, mengungkapkan dan menunjukkan tehnik untuk mengontol
cemas</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Vital
sign dalam batas normal</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-indent: -0.25in;">
<span style="font-size: small;">
<span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Postur
tubuh, ekspresi wajah, bahasa tubuh dan tingkat aktivitas menunjukkan
berkurangnya kecemasan</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 31.92%;" valign="top" width="31%">
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>NIC :</b></span></div>
<div class="MsoHeading7" style="line-height: normal;">
<span style="font-size: small;">
Anxiety
Reduction (penurunan kecemasan)</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Gunakan pendekatan yang menenangkan </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Nyatakan dengan jelas harapan terhadap pelaku pasien</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Jelaskan semua prosedur dan apa yang dirasakan selama
prosedur</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="FR">Pahami prespektif pasien terhdap situasi stres</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Temani pasien untuk memberikan keamanan dan mengurangi
takut</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Berikan informasi faktual mengenai diagnosis, tindakan
prognosis </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Dorong keluarga untuk menemani anak</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Lakukan back / neck rub</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Dengarkan dengan penuh perhatian</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Identifikasi tingkat kecemasan </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Bantu pasien mengenal situasi yang menimbulkan
kecemasan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="NL">Dorong pasien untuk mengungkapkan perasaan, ketakutan,
persepsi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Instruksikan pasien menggunakan teknik relaksasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
<span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Kolaborasi pemberian<span>
</span>obat untuk mengurangi kecemasan</span></span></div>
<div class="MsoNormal">
</div>
</td></tr>
</tbody></table>
ERFANSYAH. HRhttp://www.blogger.com/profile/07497970584312798191noreply@blogger.com0tag:blogger.com,1999:blog-2228299828902052163.post-91146909779415417602012-11-20T20:31:00.004-08:002013-03-11T10:03:24.351-07:00Asuhan Keperawatan CytoMegaloVirus Aplikasi NANDA, NIC, NOC<h3 class="post-title entry-title" itemprop="name" style="font-family: "Courier New",Courier,monospace;">
<span style="font-size: small;">
Asuhan Keperawatan CytoMegaloVirus Aplikasi NANDA, NIC, NOC
</span></h3>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span><span style="font-family: "Courier New",Courier,monospace;">
</span><span style="font-family: "Courier New",Courier,monospace;">
</span></span>
<div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; line-height: 150%;">
<span style="font-size: small;"><br /></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><h3 style="font-family: "Courier New",Courier,monospace;">
<span style="font-size: small;">
A.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Masalah
Yang lazim muncul pada klien</span></h3>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;">1.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="line-height: 150%;">Resiko penyebaran infeksi b/d penurunan system imun,
aspek kronis penyakit</span></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;">2.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="line-height: 150%;">Resiko pola nafas tidak afektif b/d penurunan energi
dalam bernafas</span></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;">3.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="line-height: 150%;">Ketidakseimbangan nutrisi kurang dari kebutuhan tubuh b/d
intake tidak adekuat, stomatitis, gangguan absorbsi, kelemahan, kehilangan
nafsu makan.</span></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;">4.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="line-height: 150%;">Nyeri akut b/d proses penyakit</span></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><b><i>5.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></i></b><span lang="NL" style="line-height: 150%;">Kurang pengetahuan mengenai penularan, penanganan dan
perjalanan penyakit</span></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; line-height: 150%;">
<span style="font-size: small;"><br /></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><h3 style="font-family: "Courier New",Courier,monospace;">
<span style="font-size: small;">
B.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Discharge
Planning</span></h3>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="IT" style="line-height: 150%;">1.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="IT" style="line-height: 150%;">Ajarkan pada orang tua tentang cara cara pencegahan
penyebaran infeksi</span></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; line-height: 150%; margin-left: 81pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="IT" style="line-height: 150%;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="IT" style="line-height: 150%;">Nasehati orang tua
tentang kemungkinan bahwa virus tetap disekresikan selama lebih dari satu tahun</span></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; line-height: 150%; margin-left: 81pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL" style="line-height: 150%;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NL" style="line-height: 150%;">Teman yang sedang hamil
tidak boleh merawat anak tersebut (mis : mengganti popok anak)</span></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; line-height: 150%; margin-left: 81pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL" style="line-height: 150%;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NL" style="line-height: 150%;">Cuci tangan dengan baik
setelah mengganti popok dan jangan mambuang popok di sembarang tempat</span></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; line-height: 150%; margin-left: 45pt; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;">2.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="line-height: 150%;">Ajarkan pada orang tua tentang penatalaksanaan jangka
panjang</span></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; line-height: 150%; margin-left: 1in; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="line-height: 150%;">Kuatkan informasi tentang virus</span></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; line-height: 150%; margin-left: 1in; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="line-height: 150%;">Jika ada sekuele neurologik, kognitif atau perkembangan
rujuklah ke lembaga berbasis masyarakat</span></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; line-height: 150%; margin-left: 1in; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span><span lang="NL" style="line-height: 150%;">Tekankan pentingnya
pemantauan medis setelah periode akut</span><span lang="NL"></span></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span><div class="MsoNormal" style="font-family: "Courier New",Courier,monospace; line-height: 150%;">
<span style="font-size: small;"><br /></span></div>
<span style="font-size: small;"><span style="font-family: "Courier New",Courier,monospace;">
</span></span>
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: medium none; font-family: "Courier New",Courier,monospace; width: 100%;"><tbody>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>No</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 32.4%;" valign="top" width="32%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>Diagnosa
keperawatan</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 27.78%;" valign="top" width="27%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>Tujuan
dan Kriteria Hasil</span></span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 34.62%;" valign="top" width="34%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><span>Intervensi</span></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
1</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 32.4%;" valign="top" width="32%"><div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><span>Resiko
penyebaran infeksi b/d penurunan system imun, aspek kronis penyakit.</span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : Peningkatan resiko masuknya organisme patogen</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Faktor-faktor resiko : </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Prosedur Infasif</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Ketidakcukupan pengetahuan untuk menghindari
paparan patogen </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Trauma </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Kerusakan jaringan dan peningkatan paparan
lingkungan </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Ruptur membran amnion</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Agen farmasi (imunosupresan)</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Malnutrisi </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Peningkatan paparan lingkungan patogen </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Imonusupresi </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Ketidakadekuatan imum buatan </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Tidak adekuat pertahanan sekunder (penurunan Hb,
Leukopenia, penekanan respon inflamasi)</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Tidak adekuat pertahanan tubuh primer (kulit tidak
utuh, trauma jaringan, penurunan kerja silia, cairan tubuh statis, perubahan
sekresi pH, perubahan peristaltik)</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Penyakit kronik</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 27.78%;" valign="top" width="27%"><div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NOC : </b></span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Immune
Status</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Knowledge
: Infection control</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Risk
control</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Klien
bebas dari tanda dan gejala infeksi</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Mendeskripsikan
proses penularan penyakit, factor yang mempengaruhi penularan serta
penatalaksanaannya,</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Menunjukkan
kemampuan untuk mencegah timbulnya infeksi</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Jumlah
leukosit dalam batas normal</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Menunjukkan
perilaku hidup sehat</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 34.62%;" valign="top" width="34%"><div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NIC :</b></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Infection Control (Kontrol infeksi)</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="FR">Bersihkan lingkungan setelah dipakai pasien lain</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="FR">Pertahankan teknik isolasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="FR">Batasi pengunjung bila perlu</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Instruksikan pada pengunjung untuk mencuci tangan saat
berkunjung dan setelah berkunjung meninggalkan pasien</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Gunakan sabun antimikrobia untuk cuci tangan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Cuci tangan setiap sebelum dan sesudah tindakan
kperawtan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Gunakan baju, sarung tangan sebagai alat pelindung</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Pertahankan lingkungan aseptik selama pemasangan alat</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Ganti letak IV perifer dan line central dan dressing
sesuai dengan petunjuk umum</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Gunakan kateter intermiten untuk menurunkan infeksi
kandung kencing </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Tingktkan intake nutrisi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span><span lang="NL">Berikan terapi antibiotik bila perlu</span></span></div>
<div class="MsoNormal" style="margin-left: 3.65pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Infection Protection (proteksi terhadap infeksi)</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Monitor tanda dan gejala infeksi sistemik dan lokal</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Monitor hitung granulosit, WBC</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Monitor kerentanan terhadap infeksi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Batasi pengunjung</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Saring pengunjung terhadap penyakit menular</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Partahankan teknik aspesis pada pasien yang beresiko</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Pertahankan teknik isolasi k/p</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Berikan perawatan kuliat pada area epidema</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Inspeksi kulit dan membran mukosa terhadap kemerahan,
panas, drainase</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Ispeksi kondisi luka / insisi bedah</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Dorong masukkan nutrisi yang cukup</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Dorong masukan cairan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Dorong istirahat</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Instruksikan pasien untuk minum antibiotik sesuai resep</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Ajarkan pasien dan keluarga tanda dan gejala infeksi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Ajarkan cara menghindari infeksi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Laporkan kecurigaan infeksi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Laporkan kultur positif</span><span></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
2</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 32.4%;" valign="top" width="32%"><div class="MsoNormal">
<span style="font-size: small;"><span>Resiko pola nafas tidak afektif b/d
penurunan energi dalam bernafas.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : Pertukaran udara inspirasi dan/atau ekspirasi tidak
adekuat</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Batasan karakteristik : </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Penurunan tekanan inspirasi/ekspirasi </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Penurunan pertukaran udara per menit </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Menggunakan otot pernafasan tambahan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Nasal flaring </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Dyspnea</span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Orthopnea </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Perubahan penyimpangan dada </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Nafas pendek </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Assumption of 3-point position </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Pernafasan pursed-lip </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Tahap ekspirasi berlangsung sangat lama </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Peningkatan diameter anterior-posterior </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Pernafasan rata-rata/minimal </span></span></div>
<div class="MsoNormal" style="margin-left: 31.85pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK">Bayi : < 25 atau >
60</span></span></div>
<div class="MsoNormal" style="margin-left: 31.85pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK">Usia 1-4 : < 20 atau
> 30</span></span></div>
<div class="MsoNormal" style="margin-left: 31.85pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK">Usia 5-14 : < 14 atau
> 25</span></span></div>
<div class="MsoNormal" style="margin-left: 31.85pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK">Usia > 14 : < 11
atau > 24</span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Kedalaman pernafasan </span></span></div>
<div class="MsoNormal" style="margin-left: 31.85pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK">Dewasa volume tidalnya
500 ml saat istirahat </span></span></div>
<div class="MsoNormal" style="margin-left: 31.85pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK">Bayi volume tidalnya 6-8
ml/Kg</span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Timing rasio </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Penurunan kapasitas vital</span><span lang="NO-BOK"></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Faktor yang berhubungan : </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Hiperventilasi </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Deformitas tulang </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Kelainan bentuk dinding dada </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Penurunan energi/kelelahan </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Perusakan/pelemahan muskulo-skeletal </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Obesitas </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Posisi tubuh </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Kelelahan otot pernafasan </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Hipoventilasi sindrom </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Nyeri </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Kecemasan </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Disfungsi Neuromuskuler </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Kerusakan persepsi/kognitif </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Perlukaan pada jaringan syaraf tulang belakang </span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Imaturitas Neurologis</span><span lang="NO-BOK"></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 27.78%;" valign="top" width="27%"><div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NOC : </b></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Respiratory
status : Ventilation</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Respiratory
status : Airway patency</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Vital
sign Status</span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 21.5pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Mendemonstrasikan batuk efektif dan suara nafas
yang bersih, tidak ada sianosis dan dyspneu (mampu mengeluarkan sputum, mampu
bernafas dengan mudah, tidak ada pursed lips)</span></span></div>
<div class="MsoNormal" style="margin-left: 21.5pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span><span>Menunjukkan
jalan nafas yang paten</span><span> (</span><span>klien tidak merasa tercekik, irama nafas,
frekuensi pernafasan dalam rentang normal, tidak ada suara nafas abnormal)</span></span></div>
<div class="MsoNormal" style="margin-left: 21.5pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span><span lang="IT">Tanda Tanda vital dalam
rentang normal (tekanan darah, nadi, pernafasan)</span><span lang="IT"></span></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 34.62%;" valign="top" width="34%"><div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NIC : </b></span></div>
<h1>
<span style="font-size: small;">
Airway Management</span></h1>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Buka jalan nafas, guanakan teknik chin lift atau jaw
thrust bila perlu</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Posisikan pasien untuk memaksimalkan ventilasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="FR">Identifikasi pasien perlunya pemasangan alat jalan
nafas buatan </span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="FR">Pasang mayo bila perlu</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="FR">Lakukan fisioterapi dada jika perlu</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="FR">Keluarkan sekret dengan batuk atau suction</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="FR">Auskultasi suara nafas, catat adanya suara tambahan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="FR">Lakukan suction pada mayo</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="FR">Berikan bronkodilator bila perlu</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="FR">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="FR">Berikan pelembab udara Kassa basah NaCl Lembab</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="FR">Atur intake untuk cairan mengoptimalkan keseimbangan.</span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span><span lang="FR">Monitor respirasi dan status O2</span></span></div>
<div class="MsoNormal" style="margin-left: 3.55pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="margin-left: 3.55pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="margin-left: 3.8pt; text-align: justify;">
<span style="font-size: small;"><b>Oxygen Therapy</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Bersihkan mulut, hidung dan
secret trakea</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Pertahankan jalan nafas yang
paten</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Atur peralatan oksigenasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Monitor aliran oksigen</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span>Pertahankan posisi pasien</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span><span>Onservasi
adanya tanda tanda hipoventilasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span><span>Monitor
adanya kecemasan pasien terhadap oksigenasi</span></span></div>
<div class="MsoNormal" style="margin-left: 3.65pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="margin-left: 3.8pt; text-align: justify;">
<span style="font-size: small;"><b>Vital sign Monitoring</b></span></div>
<ul style="margin-top: 0in;" type="square">
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Monitor TD, nadi, suhu, dan RR</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Catat adanya fluktuasi tekanan darah</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Monitor VS saat pasien berbaring, duduk,
atau berdiri</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Auskultasi TD pada kedua lengan dan
bandingkan</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Monitor TD, nadi, RR, sebelum, selama, dan
setelah aktivitas</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Monitor kualitas dari nadi</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Monitor frekuensi dan irama pernapasan</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Monitor suara paru</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Monitor pola pernapasan abnormal</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Monitor suhu, warna, dan kelembaban kulit</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Monitor sianosis perifer</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Monitor adanya cushing triad (tekanan nadi
yang melebar, bradikardi, peningkatan sistolik)</span></span></li>
<li class="MsoNormal" style="text-align: justify;"><span style="font-size: small;"><span>Identifikasi penyebab dari perubahan vital
sign</span></span></li>
</ul>
<div class="MsoNormal" style="margin-left: 0.25in; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
3</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 32.4%;" valign="top" width="32%"><div class="MsoNormal">
<span style="font-size: small;"><span>Ketidakseimbangan nutrisi kurang dari
kebutuhan tubuh b/d intake tidak adekuat, stomatitis, gangguan absorbsi,
kelemahan, kehilangan nafsu makan.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : Intake nutrisi tidak cukup untuk
keperluan metabolisme tubuh.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Batasan karakteristik : </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Berat badan 20 % atau lebih di bawah ideal </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Dilaporkan adanya intake makanan yang kurang
dari RDA (Recomended Daily Allowance) </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Membran mukosa dan konjungtiva pucat </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Kelemahan otot yang digunakan untuk
menelan/mengunyah </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Luka, inflamasi pada rongga mulut </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Mudah merasa kenyang, sesaat setelah
mengunyah makanan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Dilaporkan atau fakta adanya kekurangan
makanan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Dilaporkan adanya perubahan sensasi rasa </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Perasaan ketidakmampuan untuk mengunyah
makanan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Miskonsepsi </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Kehilangan BB dengan makanan cukup </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Keengganan untuk makan </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Kram pada abdomen </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Tonus otot jelek </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Nyeri abdominal dengan atau tanpa patologi </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Kurang berminat terhadap makanan</span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Pembuluh darah kapiler mulai rapuh </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Diare dan atau steatorrhea </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Kehilangan rambut yang cukup banyak (rontok) </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK">Suara usus hiperaktif</span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK">Kurangnya informasi, misinformasi</span><span></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Faktor-faktor yang berhubungan : </span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Ketidakmampuan pemasukan atau mencerna makanan atau
mengabsorpsi zat-zat gizi berhubungan dengan faktor biologis, psikologis atau
ekonomi.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 27.78%;" valign="top" width="27%"><div class="MsoNormal">
<span style="font-size: small;"><b>NOC :</b></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Nutritional Status : food and
Fluid Intake</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><b>Kriteria
Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Adanya peningkatan berat
badan sesuai dengan tujuan</span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Berat badan ideal sesuai
dengan tinggi badan</span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Mampu mengidentifikasi
kebutuhan nutrisi</span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Tidak ada tanda tanda
malnutrisi</span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Tidak terjadi penurunan berat
badan yang berarti</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 34.62%;" valign="top" width="34%"><div class="MsoNormal">
<span style="font-size: small;"><b>Nutrition
Management</b></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Kaji adanya alergi makanan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Kolaborasi dengan ahli gizi untuk menentukan jumlah kalori dan nutrisi
yang dibutuhkan pasien.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Anjurkan pasien untuk meningkatkan intake Fe</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Anjurkan pasien untuk meningkatkan protein dan vitamin C</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Berikan substansi gula</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Yakinkan diet yang dimakan mengandung tinggi serat untuk mencegah
konstipasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Berikan makanan yang terpilih ( sudah dikonsultasikan dengan ahli
gizi)</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Ajarkan pasien bagaimana membuat catatan makanan harian.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Monitor jumlah nutrisi dan kandungan kalori</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Berikan informasi tentang kebutuhan nutrisi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span><span>Kaji kemampuan pasien untuk mendapatkan nutrisi yang dibutuhkan</span></span></div>
<div class="MsoNormal" style="margin-left: 3.55pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><b>Nutrition
Monitoring</b></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>BB pasien dalam batas normal</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Monitor adanya penurunan berat badan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Monitor tipe dan jumlah aktivitas yang biasa dilakukan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Monitor interaksi anak atau orangtua selama makan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Monitor lingkungan selama makan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Jadwalkan pengobatan dan
tindakan tidak selama jam makan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Monitor kulit kering dan perubahan pigmentasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Monitor turgor kulit</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Monitor kekeringan, rambut kusam, dan mudah patah</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Monitor mual dan muntah</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Monitor kadar albumin, total protein, Hb, dan kadar Ht</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Monitor makanan kesukaan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Monitor pertumbuhan dan perkembangan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Monitor pucat, kemerahan, dan kekeringan jaringan konjungtiva</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Monitor kalori dan intake nuntrisi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span><span>Catat adanya edema,
hiperemik, hipertonik papila lidah dan cavitas oral.</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span><span>Catat jika lidah
berwarna magenta, scarlet</span></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
4</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 32.4%;" valign="top" width="32%"><div class="MsoNormal">
<span style="font-size: small;"><span>Nyeri akut
b/d proses penyakit</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : </span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Sensori yang tidak menyenangkan dan pengalaman
emosional yang muncul secara aktual atau potensial kerusakan jaringan atau
menggambarkan adanya kerusakan (Asosiasi Studi Nyeri Internasional): serangan
mendadak atau pelan intensitasnya dari ringan sampai berat yang dapat diantisipasi
dengan akhir yang dapat diprediksi dan dengan durasi kurang dari 6 bulan.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Batasan karakteristik : </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Laporan secara verbal atau non verbal </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Fakta dari observasi </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Posisi antalgic untuk menghindari nyeri </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Gerakan melindungi </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Tingkah laku berhati-hati</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Muka topeng </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Gangguan tidur (mata sayu, tampak capek,
sulit atau gerakan kacau, menyeringai)</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Terfokus pada diri sendiri </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Fokus menyempit (penurunan persepsi waktu,
kerusakan proses berpikir, penurunan interaksi dengan orang dan lingkungan) </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Tingkah laku distraksi, contoh : jalan-jalan,
menemui orang lain dan/atau aktivitas, aktivitas berulang-ulang)</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Respon autonom (seperti diaphoresis,
perubahan tekanan darah, perubahan nafas, nadi dan dilatasi pupil)</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Perubahan autonomic dalam tonus otot (mungkin
dalam rentang dari lemah ke kaku) </span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Tingkah laku ekspresif (contoh : gelisah,
merintih, menangis, waspada, iritabel, nafas panjang/berkeluh kesah) </span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span>-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Perubahan dalam nafsu makan dan minum</span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 2.1pt;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Faktor yang berhubungan : </span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Agen injuri (biologi, kimia, fisik, psikologis)</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 27.78%;" valign="top" width="27%"><div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NOC : </b></span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Pain
Level,</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Pain
control,</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Comfort
level</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Mampu
mengontrol nyeri (tahu penyebab nyeri, mampu menggunakan tehnik
nonfarmakologi untuk mengurangi nyeri, mencari bantuan)</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Melaporkan
bahwa nyeri berkurang dengan menggunakan manajemen nyeri</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Mampu
mengenali nyeri (skala, intensitas, frekuensi dan tanda nyeri)</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Menyatakan
rasa nyaman setelah nyeri berkurang</span></div>
<div class="MsoNormal" style="margin-left: 30.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Tanda
vital dalam rentang normal</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 34.62%;" valign="top" width="34%"><h1>
<span style="font-size: small;">
Pain Management</span></h1>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Lakukan pengkajian nyeri secara komprehensif termasuk lokasi,
karakteristik, durasi, frekuensi, kualitas dan faktor presipitasi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Observasi reaksi nonverbal dari ketidaknyamanan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Gunakan teknik komunikasi terapeutik untuk mengetahui pengalaman nyeri
pasien</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Kaji kultur yang mempengaruhi respon nyeri</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Evaluasi pengalaman nyeri masa lampau</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Evaluasi bersama pasien dan tim kesehatan lain tentang
ketidakefektifan kontrol nyeri masa lampau</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Bantu pasien dan keluarga untuk mencari dan menemukan dukungan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Kontrol lingkungan yang dapat mempengaruhi nyeri seperti suhu ruangan,
pencahayaan dan kebisingan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Kurangi faktor presipitasi nyeri</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Pilih dan lakukan penanganan nyeri (farmakologi, non farmakologi dan
inter personal)</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Kaji tipe dan sumber nyeri untuk menentukan intervensi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Ajarkan tentang teknik non farmakologi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Berikan analgetik untuk mengurangi nyeri</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Evaluasi keefektifan kontrol nyeri</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Tingkatkan istirahat</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Kolaborasikan dengan dokter jika ada keluhan dan tindakan nyeri tidak
berhasil</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span><span>Monitor penerimaan pasien tentang manajemen nyeri</span></span></div>
<div class="MsoNormal" style="margin-left: 3.55pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Analgesic Administration</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Tentukan lokasi, karakteristik, kualitas, dan derajat nyeri sebelum
pemberian obat</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Cek instruksi dokter tentang jenis obat, dosis, dan frekuensi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Cek riwayat alergi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Pilih analgesik yang diperlukan atau kombinasi dari analgesik ketika
pemberian lebih dari satu </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Tentukan pilihan analgesik tergantung tipe dan beratnya nyeri</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Tentukan analgesik pilihan, rute pemberian, dan dosis optimal</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Pilih rute pemberian secara IV, IM untuk pengobatan nyeri secara
teratur</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Monitor vital sign sebelum dan sesudah pemberian analgesik pertama
kali</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span><span>Berikan analgesik
tepat waktu terutama saat nyeri hebat</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span><span>Evaluasi efektivitas
analgesik, tanda dan gejala (efek samping)</span></span></div>
<div class="MsoNormal" style="margin-left: 3.65pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 5.2%;" valign="top" width="5%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
5</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 32.4%;" valign="top" width="32%"><div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><span>Kurang
pengetahuan mengenai penularan, penanganan dan perjalanan penyakit.</span></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : </span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Tidak adanya atau kurangnya informasi kognitif sehubungan dengan
topic spesifik.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Batasan karakteristik : memverbalisasikan adanya masalah,
ketidakakuratan mengikuti instruksi, perilaku tidak sesuai.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><span lang="NO-BOK">Faktor yang berhubungan
: keterbatasan kognitif, interpretasi terhadap informasi yang salah,
kurangnya keinginan untuk mencari informasi, tidak mengetahui sumber-sumber
informasi.</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 27.78%;" valign="top" width="27%"><div class="MsoNormal">
<span style="font-size: small;"><b>NOC :</b></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.3in;">
<span style="font-size: small;"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Kowlwdge : disease process<span></span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.3in;">
<span style="font-size: small;"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span>Kowledge : health Behavior<span></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><b>Kriteria
Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span>Pasien
dan keluarga menyatakan pemahaman tentang penyakit, kondisi, prognosis dan
program pengobatan</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span><span>Pasien
dan keluarga mampu melaksanakan prosedur yang dijelaskan secara benar</span></span></div>
<div class="MsoNormal" style="margin-left: 0.3in; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span><span>Pasien
dan keluarga mampu menjelaskan kembali apa yang dijelaskan perawat/tim
kesehatan lainnya</span></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 34.62%;" valign="top" width="34%"><div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>NIC :</b></span></div>
<div class="MsoHeading7" style="line-height: normal;">
<span style="font-size: small;">
Teaching
: disease Process</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK">Berikan penilaian
tentang tingkat pengetahuan pasien tentang proses penyakit yang spesifik </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK">Jelaskan patofisiologi
dari penyakit dan bagaimana hal ini berhubungan dengan anatomi dan fisiologi,
dengan cara yang tepat. </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK">Gambarkan tanda dan
gejala yang biasa muncul pada penyakit, dengan cara yang tepat </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK">Gambarkan proses
penyakit, dengan cara yang tepat </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK">Identifikasi kemungkinan
penyebab, dengna cara yang tepat </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK">Sediakan informasi pada
pasien tentang kondisi, dengan cara yang tepat </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK">Hindari harapan yang
kosong </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK">Sediakan bagi keluarga
atau SO informasi tentang kemajuan pasien dengan cara yang tepat </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK">Diskusikan perubahan
gaya hidup yang mungkin diperlukan untuk mencegah komplikasi di masa yang
akan datang dan atau proses pengontrolan penyakit </span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span>v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK">Diskusikan pilihan
terapi atau penanganan</span><span></span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK">Dukung pasien untuk
mengeksplorasi atau mendapatkan second opinion dengan cara yang tepat atau
diindikasikan </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span lang="NO-BOK">Eksplorasi kemungkinan
sumber atau dukungan, dengan cara yang tepat </span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span><span lang="NO-BOK">Rujuk pasien pada grup atau agensi di komunitas
lokal, dengan cara yang tepat</span></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span><span lang="NO-BOK">Instruksikan pasien mengenai tanda dan gejala untuk
melaporkan pada pemberi</span> <span lang="NO-BOK">perawatan kesehatan, dengan cara yang tepat</span></span></div>
</td></tr>
</tbody></table>
ERFANSYAH. HRhttp://www.blogger.com/profile/07497970584312798191noreply@blogger.com0tag:blogger.com,1999:blog-2228299828902052163.post-78788554980830274042012-11-20T20:30:00.003-08:002022-07-13T22:48:54.969-07:00Asuhan Keperawatan Hiperbilirubinemia Aplikasi NANDA, NIC, NOC<h3 class="post-title entry-title" itemprop="name" style="font-family: Georgia,"Times New Roman",serif;">
<span style="font-size: small;">
Asuhan Keperawatan Hiperbilirubinemia Aplikasi NANDA, NIC, NOC
</span></h3>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span>
<br />
<div class="Section1" style="font-family: Georgia,"Times New Roman",serif;">
<span style="font-size: small;"><b><span style="line-height: 150%;"></span></b></span> <span style="font-size: small;"><br /></span><br />
<h3>
<span style="font-size: small;">A.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Masalah
Yang lazim muncul pada klien</span></h3>
<div class="MsoNormal" style="line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;">1.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="line-height: 150%;">Defisit Volume cairan b/d kehilangan aktif volume cairan
(evaporasi), diare.</span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;">2.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="line-height: 150%;">Hipertermi b/d paparan lingkungan panas (efek
fototerapi), dehidrasi</span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;">3.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="line-height: 150%;">Diare b/d efek fototerapi</span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;">4.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="line-height: 150%;">Resiko kerusakan integritas kulit b/d pigmentasi
(jaundice), hipertermi, perubahan turgor kulit, eritema.</span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 45pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;">5.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="line-height: 150%;">PK : Asidosis</span></span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span style="font-size: small;"><br /></span></div>
<h3>
<span style="font-size: small;">B.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Discharge
Planning</span></h3>
<div class="MsoNormal" style="line-height: 150%; margin-left: 0.75in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;">1.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="line-height: 150%;">Ajarkan orang tua cara merawat bayi agar tidak terjadi
infeksi dan jelaskan tentang daya tahan tubuh</span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 0.75in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;">2.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="line-height: 150%;">Jelaskan pada orang tua pentingnya pemberian ASI apabila
sudah tidak ikterik. Namunbila penyebabnya bukan dari jaundice ASI tetap
diteruskan pemberiannya.</span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 0.75in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;">3.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="line-height: 150%;">jelaskan pada orang tua tentang komplikasi yang mungkin
terjadi dan segera lapor dokter/perawat</span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 0.75in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;">4.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="line-height: 150%;">jelaskan untukpemberian imunisasi</span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 0.75in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span style="line-height: 150%;">5.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="line-height: 150%;">Jelaskan tentang pengobatan yang diberikan</span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-size: small;">
<span style="line-height: 150%;"></span></span>
</div>
</div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span>
<br />
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: medium none; font-family: Georgia,"Times New Roman",serif; width: 100%;"><tbody>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 3.5%;" valign="top" width="3%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">No</span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 31.44%;" valign="top" width="31%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">Diagnosa
keperawatan</span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 29.12%;" valign="top" width="29%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">Tujuan
dan Kriteria Hasil</span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(204, 204, 204); border: 1pt solid black; padding: 0in 5.4pt; width: 35.94%;" valign="top" width="35%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">Intervensi</span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 3.5%;" valign="top" width="3%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
1</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 31.44%;" valign="top" width="31%"><div class="MsoNormal">
<span style="font-size: small;">Defisit Volume cairan b/d kehilangan aktif
volume cairan (evaporasi), diare.</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : Penurunan cairan intravaskuler,
interstisial, dan/atau intrasellular. Ini mengarah ke dehidrasi, kehilangan
cairan dengan pengeluaran sodium</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;">Batasan
Karakteristik : </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Kelemahan </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Haus </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Penurunan turgor kulit/lidah </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Membran mukosa/kulit kering </span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Peningkatan denyut nadi, penurunan tekanan
darah, penurunan volume/tekanan nadi </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Pengisian vena menurun </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Perubahan status mental</span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Konsentrasi urine meningkat </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Temperatur tubuh meningkat </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span><span lang="NO-BOK">Hematokrit meninggi </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span><span lang="NO-BOK">Kehilangan berat badan seketika (kecuali pada third spacing)</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Faktor-faktor yang berhubungan: </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span><span lang="NO-BOK">Kehilangan volume cairan secara aktif </span></span></div>
<div class="MsoNormal" style="margin-left: 13.85pt; text-indent: -9pt;">
<span style="font-size: small;">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span><span lang="NO-BOK">Kegagalan mekanisme pengaturan</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 29.12%;" valign="top" width="29%"><div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NOC: </b></span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Fluid
balance</span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Hydration</span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Nutritional
Status : Food and Fluid Intake</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Mempertahankan
urine output sesuai dengan usia dan BB, BJ urine normal, HT normal</span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Tekanan
darah, nadi, suhu tubuh dalam batas normal</span></div>
<div class="MsoNormal" style="margin-left: 24.4pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Tidak
ada tanda tanda dehidrasi, Elastisitas turgor kulit baik, membran mukosa
lembab, tidak ada rasa haus yang berlebihan</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 35.94%;" valign="top" width="35%"><div class="MsoBodyTextIndent" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>NIC :</b></span></div>
<div class="MsoHeading9">
<span style="font-size: small;">
Fluid management</span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Timbang popok/pembalut jika diperlukan </span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Pertahankan catatan intake dan output yang akurat</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Monitor status hidrasi ( kelembaban membran mukosa,
nadi adekuat, tekanan darah ortostatik ), jika diperlukan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Monitor vital sign</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Monitor masukan makanan / cairan dan hitung intake
kalori harian</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Kolaborasikan pemberian cairan IV </span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Monitor status nutrisi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Berikan cairan IV pada suhu ruangan </span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Dorong masukan oral</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Berikan penggantian nesogatrik sesuai output</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Dorong keluarga untuk membantu pasien makan</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span>Tawarkan snack ( jus
buah, buah segar )<span lang="NL"></span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NL">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NL">Kolaborasi dokter jika tanda cairan berlebih muncul
meburuk </span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span><span lang="NL">Atur kemungkinan tranfusi</span></span></div>
<div class="MsoNormal" style="margin-left: 21.55pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span><span lang="NL">Persiapan untuk tranfusi</span></span></div>
<div class="MsoBodyTextIndent" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>Hypovolemia
Management</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Monitor status cairan termasuk intake dan ourput
cairan</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Pelihara IV line</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Monitor tingkat Hb dan hematokrit</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Monitor tanda vital</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Monitor responpasien terhadap penambahan cairan</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Monitor berat badan</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Dorong pasien untuk menambah intake oral</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Pemberian cairan Iv monitor adanya tanda dan
gejala kelebihanvolume cairan</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Monitor
adanya tanda gagal ginjal</span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 3.5%;" valign="top" width="3%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
2</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 31.44%;" valign="top" width="31%"><div class="MsoBodyText2">
<span style="font-size: small;">
Hipertermi b/d paparan
lingkungan panas (efek fototerapi), dehidrasi</span></div>
<div class="MsoBodyText2">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Definisi : suhu tubuh naik diatas rentang normal</span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Batasan Karakteristik:</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">kenaikan suhu tubuh diatas rentang normal</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">serangan atau konvulsi (kejang)</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">kulit kemerahan</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">pertambahan RR</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">takikardi</span></span></div>
<div class="MsoNormal" style="margin-left: 20.1pt; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">saat disentuh tangan terasa hangat</span></span></div>
<div class="MsoNormal" style="margin-left: 2.1pt;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span lang="NO-BOK">Faktor faktor yang berhubungan :</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">penyakit/ trauma</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">peningkatan metabolisme</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">aktivitas yang berlebih</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">pengaruh medikasi/anastesi</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">ketidakmampuan/penurunan kemampuan untuk
berkeringat</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">terpapar dilingkungan panas</span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">dehidrasi</span><span lang="NO-BOK"></span></span></div>
<div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">-<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">pakaian yang tidak tepat</span><span lang="NO-BOK"></span></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 29.12%;" valign="top" width="29%"><div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>NOC </b>: Thermoregulation</span></div>
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Suhu tubuh dalam rentang normal</span></div>
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Nadi dan RR dalam rentang normal</span></div>
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 29.75pt; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Tidak ada perubahan warna kulit dan tidak ada
pusing</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 35.94%;" valign="top" width="35%"><div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>NIC :</b></span></div>
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>Fever
treatment</b></span></div>
<div class="MsoNormal" style="margin-left: 30.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Monitor suhu sesering mungkin</span></div>
<div class="MsoNormal" style="margin-left: 30.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Monitor IWL</span></div>
<div class="MsoNormal" style="margin-left: 30.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Monitor warna dan suhu kulit</span></div>
<div class="MsoNormal" style="margin-left: 30.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Monitor tekanan darah, nadi dan RR</span></div>
<div class="MsoNormal" style="margin-left: 30.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Monitor penurunan tingkat kesadaran</span></div>
<div class="MsoNormal" style="margin-left: 30.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Monitor WBC, Hb, dan Hct</span></div>
<div class="MsoNormal" style="margin-left: 30.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Monitor intake dan output</span></div>
<div class="MsoNormal" style="margin-left: 30.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Berikan anti piretik</span></div>
<div class="MsoNormal" style="margin-left: 30.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Berikan pengobatan untuk mengatasi penyebab demam</span></div>
<div class="MsoNormal" style="margin-left: 30.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Selimuti pasien</span></div>
<div class="MsoNormal" style="margin-left: 30.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Lakukan tapid sponge</span></div>
<div class="MsoNormal" style="margin-left: 30.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Berikan cairan intravena</span></div>
<div class="MsoNormal" style="margin-left: 30.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Kompres pasien pada lipat paha dan aksila</span></div>
<div class="MsoNormal" style="margin-left: 30.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Tingkatkan sirkulasi udara</span></div>
<div class="MsoNormal" style="margin-left: 30.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Berikan
pengobatan untuk mencegah terjadinya menggigil</span></div>
<div class="MsoNormal" style="margin-left: 12.65pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoBodyTextIndent2" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>Temperature
regulation</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Monitor suhu minimal tiap 2 jam</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Rencanakan monitoring suhu secara kontinyu</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Monitor TD, nadi, dan RR</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Monitor warna dan suhu kulit</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Monitor tanda-tanda hipertermi dan hipotermi</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Tingkatkan intake cairan dan nutrisi</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Selimuti pasien untuk mencegah hilangnya kehangatan tubuh</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Ajarkan pada pasien cara mencegah keletihan akibat panas</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Diskusikan tentang pentingnya pengaturan suhu dan kemungkinan efek
negatif dari kedinginan</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Beritahukan tentang indikasi terjadinya keletihan dan penanganan
emergency yang diperlukan</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Ajarkan indikasi dari hipotermi dan penanganan yang diperlukan</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -14.2pt;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Berikan anti piretik jika
perlu</span></div>
<div class="MsoNormal" style="margin-left: 7.45pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Vital sign Monitoring</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Monitor TD, nadi, suhu, dan RR</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Catat adanya fluktuasi tekanan darah</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Monitor VS saat pasien berbaring, duduk, atau berdiri</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Auskultasi TD pada kedua lengan dan bandingkan</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Monitor TD, nadi, RR, sebelum, selama, dan setelah aktivitas</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Monitor kualitas dari nadi</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Monitor frekuensi dan irama pernapasan</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Monitor suara paru</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Monitor pola pernapasan abnormal</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Monitor suhu, warna, dan kelembaban kulit</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Monitor sianosis perifer</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Monitor
adanya cushing triad (tekanan nadi yang melebar, bradikardi, peningkatan
sistolik)</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Identifikasi penyebab dari
perubahan vital sign<b> </b></span></div>
<div class="MsoNormal" style="margin-left: 3.65pt; text-align: justify;">
<span style="font-size: small;"><br /></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 3.5%;" valign="top" width="3%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
3</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 31.44%;" valign="top" width="31%"><div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-size: small;"><span style="line-height: 150%;">Diare b/d efek fototerapi</span></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 29.12%;" valign="top" width="29%"><div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NOC: </b></span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Bowel
elimination</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Fluid
Balance</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Hydration</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Electrolyte
and Acid base Balance</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Feses
berbentuk, BAB sehari sekali- tiga hari</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Menjaga
daerah sekitar rectal dari iritasi</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Tidak
mengalami diare</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Menjelaskan
penyebab diare dan rasional tendakan</span></div>
<div class="MsoNormal" style="margin-left: 29.75pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Mempertahankan
turgor kulit</span></div>
<div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 35.94%;" valign="top" width="35%"><div class="MsoBodyTextIndent" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>NIC :</b></span></div>
<div class="MsoBodyTextIndent" style="line-height: normal; margin-left: 0in;">
<span style="font-size: small;"><b>Diarhea
Management</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Evaluasi efek samping pengobatan terhadap
gastrointestinal</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Ajarkan pasien untuk menggunakan obat antidiare</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Instruksikan pasien/keluarga untukmencatat warna,
jumlah, frekuenai dan konsistensi dari feses</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Evaluasi intake makanan yang masuk</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Identifikasi factor penyebab dari diare</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Monitor tanda dan gejala diare</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Observasi turgor kulit secara rutin</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Ukur diare/keluaran BAB</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Hubungi dokter jika ada kenanikan bising usus</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Instruksikan pasien untukmakan rendah serat,
tinggi protein dan tinggi kalori jika memungkinkan</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Instruksikan untuk menghindari laksative</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Ajarkan tehnik menurunkan stress</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Monitor
persiapan makanan yang aman</span></div>
<div class="MsoNormal" style="margin-left: 3.65pt;">
<span style="font-size: small;"><br /></span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 3.5%;" valign="top" width="3%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
4</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 31.44%;" valign="top" width="31%"><div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;">Resiko
kerusakan integritas kulit b/d pigmentasi (jaundice), hipertermi, perubahan
turgor kulit, eritema.</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 29.12%;" valign="top" width="29%"><div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>NOC </b>:
Tissue Integrity : Skin and Mucous Membranes</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>Kriteria Hasil :</b></span></div>
<div class="MsoNormal" style="margin-left: 39.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Integritas
kulit yang baik bisa dipertahankan (sensasi, elastisitas, temperatur,
hidrasi, pigmentasi)</span></div>
<div class="MsoNormal" style="margin-left: 39.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Tidak
ada luka/lesi pada kulit</span></div>
<div class="MsoNormal" style="margin-left: 39.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Perfusi
jaringan baik</span></div>
<div class="MsoNormal" style="margin-left: 39.7pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Menunjukkan
pemahaman dalam proses perbaikan kulit dan mencegah terjadinya sedera
berulang</span></div>
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<span style="font-size: small;">
v<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Mampu
melindungi kulit dan mempertahankan kelembaban kulit dan perawatan alami</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 35.94%;" valign="top" width="35%"><div class="MsoNormal">
<span style="font-size: small;"><b>NIC </b>: <b>Pressure Management</b></span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Anjurkan pasien untuk menggunakan pakaian yang longgar</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Hindari kerutan padaa tempat tidur</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Jaga kebersihan kulit agar tetap bersih dan kering</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Mobilisasi pasien (ubah posisi pasien) setiap dua jam sekali</span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Monitor kulit akan adanya kemerahan </span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Oleskan lotion atau minyak/baby oil pada derah yang tertekan </span></div>
<div class="MsoNormal" style="margin-left: 21.65pt; text-align: justify; text-indent: -0.25in;">
<span style="font-size: small;">§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Monitor aktivitas dan mobilisasi pasien</span></div>
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<span style="font-size: small;">
§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Monitor status
nutrisi pasien</span></div>
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<span style="font-size: small;">
§<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span>Memandikan pasien
dengan sabun dan air hangat</span></div>
</td>
</tr>
<tr>
<td style="border: 1pt solid black; padding: 0in 5.4pt; width: 3.5%;" valign="top" width="3%"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;">
5</span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 31.44%;" valign="top" width="31%"><div class="MsoNormal">
<span style="font-size: small;">PK : Asidosis </span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 29.12%;" valign="top" width="29%"><div class="MsoNormal">
<span style="font-size: small;"><br /></span></div>
</td>
<td style="border-color: -moz-use-text-color black black -moz-use-text-color; border-style: none solid solid none; border-width: medium 1pt 1pt medium; padding: 0in 5.4pt; width: 35.94%;" valign="top" width="35%"><div class="MsoHeading7" style="line-height: normal;">
<span style="font-size: small;"><span lang="NO-BOK">Asidosis Metabolik</span></span></div>
<div class="MsoNormal" style="margin-left: 0.25in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">1.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Pantau tanda dan gejala asidosis metabolik</span></span></div>
<ol start="1" style="margin-top: 0in;" type="1"><ol start="1" style="margin-top: 0in;" type="a">
<li class="MsoNormal"><span style="font-size: small;"><span lang="NO-BOK">pernafasan cepat
danlambat</span></span></li>
<li class="MsoNormal"><span style="font-size: small;"><span lang="NO-BOK">sakit kepala</span></span></li>
<li class="MsoNormal"><span style="font-size: small;"><span lang="NO-BOK">mual dan muntah</span></span></li>
<li class="MsoNormal"><span style="font-size: small;"><span lang="NO-BOK">bikarbonat plasma
dan pH arteri darah rendah</span></span></li>
<li class="MsoNormal"><span style="font-size: small;"><span lang="NO-BOK">perubahan tingkah
laku, mengantuk</span></span></li>
<li class="MsoNormal"><span style="font-size: small;"><span lang="NO-BOK">kalsium serum
meningkat</span></span></li>
<li class="MsoNormal"><span style="font-size: small;"><span lang="NO-BOK">klorida serum
meningkat</span></span></li>
<li class="MsoNormal"><span style="font-size: small;"><span lang="NO-BOK">penurunan HCO<sub>3</sub></span></span></li>
</ol>
</ol>
<div class="MsoNormal" style="margin-left: 0.25in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">2.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Untuk klien klien dengan asidosis metabolik</span></span></div>
<ol start="2" style="margin-top: 0in;" type="1"><ol start="1" style="margin-top: 0in;" type="a">
<li class="MsoNormal"><span style="font-size: small;"><span lang="NO-BOK">mulai dengan
penggantian cairan IV sesuai program tergantung dari penyebab dasarnya.</span></span></li>
<li class="MsoNormal"><span style="font-size: small;"><span lang="NO-BOK">Jika etiologinya
DM, rujuk pada PK: hipo/hiperglikemia</span></span></li>
<li class="MsoNormal"><span style="font-size: small;"><span lang="NO-BOK">Kaji tanda
dangejala hipokalsemia, hipokalemia, dan alkalosis setelah asidosisnya
terkoreksi</span></span></li>
<li class="MsoNormal"><span style="font-size: small;"><span lang="NO-BOK">Lakukan koreksi
pada setiap gangguan ketidakseimbangan elektrolit sesuai dengan program
dokter</span></span></li>
<li class="MsoNormal"><span style="font-size: small;"><span lang="NO-BOK">Pantau nilai gas
darah arteri dan pH urine.</span></span></li>
</ol>
</ol>
<div class="MsoNormal" style="margin-left: 0.75in;">
<span style="font-size: small;"><br /></span></div>
<div class="MsoHeading7" style="line-height: normal;">
<span style="font-size: small;"><span lang="NO-BOK">Untuk asidosis Respiratorik</span></span></div>
<div class="MsoNormal" style="margin-left: 0.25in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">1.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">Pantau tanda dan gejala asidosis respiratorik</span></span></div>
<ol start="1" style="margin-top: 0in;" type="1"><ol start="1" style="margin-top: 0in;" type="a">
<li class="MsoNormal"><span style="font-size: small;"><span lang="NO-BOK">takikardi</span></span></li>
<li class="MsoNormal"><span style="font-size: small;"><span lang="NO-BOK">disritmia</span></span></li>
<li class="MsoNormal"><span style="font-size: small;"><span lang="NO-BOK">berkeringat</span></span></li>
<li class="MsoNormal"><span style="font-size: small;"><span lang="NO-BOK">mual/muntah</span></span></li>
<li class="MsoNormal"><span style="font-size: small;"><span lang="NO-BOK">gelisah</span></span></li>
<li class="MsoNormal"><span style="font-size: small;"><span lang="NO-BOK">dyspneu</span></span></li>
<li class="MsoNormal"><span style="font-size: small;"><span lang="NO-BOK">peningkatan usaha
nafas</span></span></li>
<li class="MsoNormal"><span style="font-size: small;"><span lang="NO-BOK">penurunan
frekuensi pernafasan</span></span></li>
<li class="MsoNormal"><span style="font-size: small;"><span lang="NO-BOK">peningkatan PCO<sub>2</sub></span></span></li>
<li class="MsoNormal"><span style="font-size: small;"><span lang="NO-BOK">peningkatan
kalsium serum</span></span></li>
<li class="MsoNormal"><span style="font-size: small;"><span lang="NO-BOK">penurunan natrium
klorida</span></span></li>
</ol>
</ol>
<div class="MsoNormal" style="margin-left: 0.25in; text-indent: -0.25in;">
<span style="font-size: small;"><span lang="NO-BOK">2.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span lang="NO-BOK">untuk klien klien dengan asidosis respiratorik</span></span></div>
<ol start="2" style="margin-top: 0in;" type="1"><ol start="1" style="margin-top: 0in;" type="a">
<li class="MsoNormal"><span style="font-size: small;"><span lang="NO-BOK">perbaiki ventilasi
melalui pengubahan posisi pada semifowler, latihan nafas dalam</span></span></li>
<li class="MsoNormal"><span style="font-size: small;"><span lang="NO-BOK">konsul kemungkinan
penggunaan ventilasi mekanis</span></span></li>
<li class="MsoNormal"><span style="font-size: small;"><span lang="NO-BOK">berikan oksigen
setelah klien dapat bernafas dengan baik</span></span></li>
<li class="MsoNormal"><span style="font-size: small;"><span lang="NO-BOK">tingkatkan
pemberian hidrasi yang optimal</span></span></li>
</ol>
</ol>
</td></tr>
</tbody></table>
ERFANSYAH. HRhttp://www.blogger.com/profile/07497970584312798191noreply@blogger.com2