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Askep Stroke Iskemik

Askep Stroke Iskemik

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Published by: Indah Hermayoni on Nov 25, 2013
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03/24/2014

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10. ASUHAN KEPERAWATAN PADA KLIEN DENGAN STROKE ISKEMIK Diagnosa 1. P!ru$a%an &!r'usi jaringan o a( $!r%u$ungan )!ngan &!

r)ara%an in ras!r!$ra"* o("usi o a(* #asos&as+! )an !)!+a o a( Tujuan & Kri !ria Hasi" S! !"a% )i"a(u(an asu%an (!&!ra,a an s!"a+a ...-./ ja+ )i%ara&(an &!r'usi jaringan o a( )a&a !r0a&ai s!0ara o& i+a" )!ngan KH1 1. K"i!n i)a( g!"isa% .. Ti)a( a)a (!"u%an n2!ri (!&a"a* +ua"* )an (!jang 3. G4S /*5*6 /. Pu&i" iso(or 5. R!'"!( 0a%a2a 789 6. TT: nor+a" 7na)i1 60;100- &!r +!ni * su%u1 36;36*<04* HR1 16;.0- &!r +!ni 9 In !r#!nsi 1. =!ri(an &!nj!"asan (!&a)a (!"uarga ("i!n !n ang s!$a$ &!ning(a an TIK )an a(i$a n2a .. =aring(an ("i!n o a" )!ngan &osisi i)ur !r"!n ang an&a $an a" 3. Moni or an)a; an)a s a us n!uro"ogis )!ngan G4S /. Moni or TT: s!&!r i TD* na)i* su%u r!s&irasi )an %a i;%a i &a)a %i&!r !nsi sis o"i( 5. Moni or in&u )an ou &u 6. =an u &asi!n un u( +!+$a asi +un a%* $a u(. Anjur(an &asi!n un u( +!ng!"uar(an na'as a&a$i"a $!rg!ra( a au $!r$a"i( !+&a i)ur. <. Anjur(an ("i!n un u( +!ng%in)ari $a u( )an Rasiona" 1. K!"uarga "!$i% $!r&ar isi&asi )a"a+ &ros!s &!n2!+$u%an .. P!ru$a%an &a)a !(anan in ra0rania" )a&a +!n2!$a$(an !rjasin2a %!rniasi o a( 3. Da&a +!ngurangi (!rusa(an o a( "!$i% "anju /. Pa)a (!a)aan nor+a"* o or!gu"asi +!+&!r a%an(an (!a)aan !(anan )ara% sis !+i( $!ru$a% s!0ara '"u( uasi. K!gaga"an o or!gu"!r a(an +!n2!$a$(an (!rusa(an #as(u"!r s!r!$ri 2ang )a&a )i+ani'!s asi(an )!ngan &!ning(a an sis o"i( )an )ii(u i o"!% &!nurunan !(anan )ias o"i0* s!)ang(an &!ning(a an su%u

Rangsangan a( i#i as 2ang +!ning(a )a&a +!ning(a (an (!nai(an TIK Ko"a$orasi1 1. >. Moni or AGD $i"a )i&!r"u(an &!+$!rian o(sig!n +!ngga+$ar(an &!rja"anan in'!(si 5.a( u $!rg!ra( a au +!ngu$a% &osisi )a&a +!"in)ungi )iri )ari rasa n2!ri <. A( i#i as ini )a&a +!ning(a (an !(anan in ra0rania" )an in raa$)o+!n. .+!ng!jan $!r"!$i%an. Hi&!r !r+i )a&a +!ning(a (an r!si(o )!%i)rasi !ru a+a &a)a ("i!n 2ang i)a( sa)ar* +ua" 2ang +!nurun(an asu&an 6. =a u( )an +!ng!jan )a&a +!ning(a (an !(anan in ra0rania" >. 4i& a(an "ing(ungan 2ang !nang )an $a asi &!ngunjung Ko"a$orasi1 1 =!ri(an 0airan &!rin'us )!ngan &!r%a ian (! a . M!+ini+a"(an '"u( uasi &a)a $!$an #as(u"!r )an !(anan in ra0rania" * r! ri(si 0airan. M!ng!"uar(an na&as s!.

P!ru$a%an nu risi (urang )ari (!$u u%an u$u% 2ang $!r%u$ungan )!ngan (!"!+a%an oo +!ngun2a% )an +!n!"an S! !"a% )i"a(u(an in !r#!nsi s!"a+a . 3.. +!ng%in)ari (o+&"i(asi s!(un)!r a(i$a a"!rgi . asu&an nu risi 2ang +asu( 0u(u& )!ngan s(a"a 5 3. +!+u)a%(an &!+$!rian nu risi 1./ja+*)i%ara&(an in a(! +a(anan ("i!n a)!(ua )!ngan (ri !ria %asi" 1 1. +!ng! a%ui &!r(!+$angan &!+!nu%an nu risi ("i!n 5..a( u .. =!ri(an &!nj!"asan &a)a ("i!n )an (!"uarga !n ang 1. Asu&an +a(anan 2ang +asu( s!suai (!$u u%an )!ngan s(a"a 5 . Gangguan !"i+inasi a"#i Tujuan 1 )a"a+ .. ... A)an2a (!+ung(inan asi)osis )is!r ai )!ngan &!"!&asan o(sig!n &a)a ing(a s!" )a&a +!n2!$a$(an !rja)in2a . 5... 1. )i! 2ang )i$!ri(an (!&a)a ("i!n s!suai )!ngan (!$u u%an u$u% 3. K"i!n )an (!"uarga a(an +!ng!r i !n ang &!n2!$a$ . +!ning(a (an na'su +a(an ("i!n /.-. ./ ja+ &!+!nu%an /. Tan2a(an &a)a (!"uarga $i"a ("i!n +!+i"i(i a"!rgi &a)a +a(anan !r !n u "a(u(an (o"a$orasi )!ngan a%"i gi?i !n ang $ra&a $an2a( (a"ori )an 'or+u"a +a(anan 2ang )i$u u%(an ("i!n s!)ia(an &i"i%an +a(anan 2ang 0o0o( un u( (!a)aan ("i!n &an au asu&an nu risi )an (a"ori ("i!n "a(u(an &!+asangan s!"ang NGT is(!+ia s!r!$ri 1.

=ising usus +!nan)a(an si'a a( i#i as &!ris a" i0 3. $ising usus nor+a" 715. . 5. 3. !"i+inasi a"#i !r&!nu%i )!ngan (ri !ria %asi" 1 1./ ja+ ("i!n 1. P!"una( '!s! +!ning(a (an !'isi!nsi &!+$asa%an air usus* 2ang +!"una((an +assa '!s!s )an +!+$an u !"i+inasi. Kaji .-. A( i#i as 'isi( r!gu"ar +!+$an u !"i+inasi )!ngan +!+&!r$ai(i onus o o a$)o+!n )an +!rangsang na'su +a(an )an &!ris a" i0. 1.a an s!"a+a A. /.30-@+!ni 9 &!n2!$a$ (ons i&asi. Aus(u" asi $ising usus.7(ons i&asi9 2ang $!r%u$ungan )!ngan i+o$i"isasi* asu&an 0airan 2ang i)a( a)!(ua .. Ha+$a an +o$i"i as 'isi( 2ang S! !"a% )i"a(u(an in)a(an (!&!ra.. i)a( !ra$a +assa &a)a (o"on 7s0i$a"a9 /. Kaji +o$i"i as 2ang a)a )an o$s!r#asi !r%a)a& &!ning(a an (!rusa(an. "i !r@%ari9 ji(a i)a( a)a (on rain)i(asi 5. Masu((an 0airan a)!(ua +!+$an u +!+&!r a%an(an (onsis !nsi '!s!s 2ang s!suai &a)a usus )an +!+$an u !"i+inasi r!gu"ar. =i"a ("i!n +a+&u +inu+* $!ri(an asu&an 0airan 2ang 0u(u& 7. La(u(an +o$i"isasi s!suai )!ngan (!a)aan ("i!n. /. Anjur(an &a)a ("i!n un u( +a(an +a(anan 2ang +!ngan)ung s!ra . (onsis !nsi '!s!s "!+$!( $!r$!n u( 3. 6. Di! s!i+$ang inggi (an)ungan s!ra +!rangsang &!ris a" i0 )an !"i+inasi r!gu"ar. ("i!n )a&a )!'!(asi s!0ara s&on an )an "an0ar an&a +!ngguna(an o$a . 6.. Ko"a$orasi )!ngan i+ )o( !r )a"a+ &!+$!rian &!"una( '!s!s 7"a(sa i'* su&osi oria* !n!+a9. (ons i&asi . M!ng! a%ui ing(a (!+a+&uan ("i!n )a"a+ +!"a(u(an a( i#i as /.

Ajar(an ("i!n un u( +!"a(u(an "a i%an g!ra( a( i' &a)a !(s r!+i as 2ang i)a( sa(i /. G!ra(an a( i' +!+$!ri(an +assa* onus )an (!(ua an o o * s!r a +!+&!r$ai(i 'ungsi jan ung )an &!rna&asan /. O o #o"un !!r a(an (!%i"angan onus )an (!(ua ann2a $i"a i)a( )i"a i% un u( )ig!ra((an 5. s!0ara !ra ur 'ungsi +o ori0 . Pan au (u"i )an +!+$ran! +u(osa !r%a)a& iri asi* (!+!ra%an* a au "!0! .. +!ning(a n2a (!(ua an o o /. Ins&!(si (u"i $agian )is a" s! ia& %ari. =!) $oar) 7 !+&a i)ur )!ngan a"as (a2u a au (asur $usa 2ang (!ras 2ang i)a( . K"i!n )a&a i(u s!r a )a"a+ &rogra+ "a i%an .$!r%u$ungan )!ngan %!+i&ar!s!@%! +i&"!g* (!"!+a%an n!uro+us0u"ar &a)a !(s r!+i as. M!+!"i%ara $!n u( u"ang $!"a(ang )!ngan 0ara 1 . P!r a%an(an s!n)i B00 !r%a)a& &a&an (a(i 6. T!"a&a( (a(i )a"a+ &osisi B00 )a&a +!n0!ga% 'oo )ro& 6. +a+&u +!"a(sana(an a( i#i as 'isi( s!suai )!ngan (!+a+&uann2a )!ngan (ri !ria Hasi" 1 1. La(u(an g!ra( &asi' &a)a !(s r!+i as 2ang sa(i 5. Un u( +!+!"i%ara '"!(si$i"i as s!n)i s!suai (!+a+&uan . D! !(si )ini a)an2a gangguan sir(u"asi )an %i"angn2a s!nsasi risi(o inggi (!rusa(an in !gri as (u"i (!+ung(inan (o+&"i(asi i+o$i"isasi <.a an )iri s!suai o"!ransi >. =an u ("i!n +!"a(u(an "a i%an ROM* &!ra.. Ma ras . i)a( !rja)i (on ra( ur s!n)i 3. "!0! <. M!nurun(an risi(o !rja)in2a is(!+ia jaringan a(i$a sir(u"asi )ara% 2ang j!"!( &a)a )a!ra% 2ang !r !(an 3. ("i!n +!nunju((an in)a(an un u( +!ning(a (an +o$i"i as. U$a% &osisi ("i!n ia& .. ja+ 3.

=!)a(an a'asia )!ngan )isa ria 3. P!ning(a an (!+a+&uan )a"a+ +o$i"isasi !(s r!+i as )a&a )i ing(a (an )!ngan "a i%an 'isis )ari i+ 'isio !ra&is 1. Kaji i&! )is'ungsi +isa"n2a ("i!n i)a( +!ng!r i !n ang (a a. M!+$an u +!n!n u(an ar!a (!rusa(an &a)a o a( )an +!n!n u(an (!su"i an ("i!n )!ngan s!$agian a au s!"uru% &ros!s (o+uni(asi* ("i!n +ung(in +!+&un2ai +asa"as )a"a+ +!ngar i(an (a a. K"i!n )a&a (!%i"angan (!+a+&uan un u( +!+an au u0a&ann2a* (o+uni(asin2a s!0ara i)a( sa)ar* )!ngan +!"!ng(a&i )a&a +!r!a"isasi(an &!ng!r ian ("i!n )an )a&a 5. Da&a +!n!n u(a &i"i%an in !r#!nsi in !r#!nsi s!suai i&! gangguan 3.(a a . K!rusa(an (o+uni(asi #!r$a" $!r%u$ungan )!ngan !'!( )ari (!rusa(an &a)a ar!a $i0ara &a)a %!+is'!r o a( * (!%i"angan 0on ro" onus o o 'a0ia" a au ora"* )an (!"!+a%an s!0ara u+u+ S! !"a% )i$!ri(an in !r#!nsi s!"a+a A. M!+&!r a%an(an &osisi u"ang $!"a(ang ! a& ra a B./ ja+ )i%ara&(an ("i!n )a&a +!nunju((an &!ng!r ian !r%a)a& +asa"a% (o+uni(asi* +a+&u +!ng!(s&r!si(an &!rasaann2a* +a+&u +!ngguna(an $a%asa is2ara )!ngan (ri !ria %asi"1 1.+!ni+$u"(an "!(u(an saa ("i!n i)ur9 B.. La(u(an +! o)! &!r0a(a&an 2ang $ai( )an "!ng(a& $!ri (!s!+&a an ("i!n un u( +!ng("ari'i(asi /. T!r0i& an2a %u$ungan (o+uni(asi )i+ana (!$u u%an ("i!n 1. Ka a(an un u( +!ngi(u i &!rin a% s!0ara s!)!r%ana s!&!r i 1 u u& +a a+u a au "i%a (! &in u 5.(a a a au +asa"a% $!r$i0ara a au i)a( +!ng!r i $a%asa s!n)iri . P!rin a%(an ("i!n un u( +!n2!$u (an na+a sua u .. Ko"a$orasi )!ngan a%"i 'isio !ra&is un u( "a i%an 'isi( ("i!n >.

An isi&asi )an $an u (!$u u%an ("i!n B.a( u un u( $!r!s&on 11. ("i!n )a&a +!r!s&on s! ia& (o+uni(asi $ai( #!r$a" +au&un is2ara $!n)a 2ang )i&!r%a i(an 6. M!ngurangi (!$ingunagn a au (!0!+asan !r%a)a& $an2a(n2a in'or+asi.)a&a )i&!nu%i .Anjur(an &!ngunjung un u( $!r(o+uni(asi )!ngan ("i!n +isa"n2a +!+$a0a sura * +!ng("ari'i(asi &!r0a(a&an /. =!ri(an ("i!n .. a&i . M!nguji a'asia !(s&r!si' +isa"n2a ("i!n )a&a +!ng!na"i $!n)a !rs!$u i)a( +a+&u +!n2!$u (an na+an2a 6.a$an i2a a au i)a( )an &!r%a i(an r!s&on ("i!n 10. M!+$!ri(an (o+uni(asi )asar s!suai )!ngan si uasi in)i#i)u >. M!ngi)!n i'i(asi )isa ria (o+&on!n $!r$i0ara 7"i)a%* g!ra(an $i$ir* 0on ro" &!rna'asan )a& +!+!ngaru%i ar i(u"asi* )an +ung(in i)a( !rja)in2a a'asia !(s&r!si' <. M!+$an u +!nurun(an 'rus asi o"!% (ar!na (! !rgan ungan )an (! i)a(+a+&uan $!r(o+uni(asi B. U0a&(an "angsung (!&a)a ("i!n $!r$i0ara &!"an )an !nang* guna(an &!r an2aan )!ngan ja. Pi"i% +! o)! (o+uni(asi a" !rna i#! +isa"n2a +!nu"is &a)a &a&an u"is* +!ngga+$ar* )an +!n)!+ons rasi(an s!0ara #isua" g!ra(an angan >. Un u( +!nguji a'asia r!s!& i' 5.=!r$i0ara )!ngan na)a nor+a" )an %in)ari u0a&an 2ang !r"a"u 0!&a . P!r)!ngar(an $un2i s!)!r%ana s!&!r i Cs%%* 0a D <.

M!ng(aji (!+a+&uan #!r$a" in)i#i)ua" )an s!nsori( +o ori( )an 'ungsi (ogni i' un u( +!ngi)!n i'i(asi )!'i0i )an (!$u u%an !ra&i 1./ ja+* )i%ara&(an (!u u%an (u"i ("i!n !rjaga )!ngan 0ri !ria %asi" 1 1. M!ning(a (an a"iran )ara% (!s!+ua $agian u$u% .Ko"a$orasi1 (onsu" asi(an (! a%"i !ra&i $i0ara M!+anju(an s i+u"asi inga an )an (a a. M!nurun(an iso"asi so0ia" )an +!ng!'!( i'(an (o+uni(asi 1. U$a% &osisi s! ia& . M!ng%in)ari !(anan 2ang $!r"!$i% &a)a ar!a 2ang +!nonjo" /. M!ng%in)ari (!rusa(an 6.a% )a!ra% )a!r%a 2ang +!nonjo" /.. M!ng%in)ari !(anan )an +!ning(a (an a"iran )ara% 3. Ti)a( a)a an)a an)a (!+!ra%an a au "u(a 1. R!si(o gangguan in !gri as (u"i 2ang $!r%u$ungan )!ngan ira% $aring 2ang "a+a S! !"a% )i$!ri(an in !r#!nsi s!"a+a A-. Anjur(an un u( +!"a(u(an "a i%an ROM .(a a 10.+!+$i0ara(an (!"uarga 1. ja+ 3.. Guna(an $an a" air a au &!ngganja" 2ang "una( )i $a.. La(u(an +asas! &a)a )a!ra% 2ang +!nonjo" 2ang $aru +!nga"a+i .. K"i!n i)a( )i&a(sa un u( +!n)!ngar* i)a( +!n2!$a$(an ("i!n +ara% )an 'rus asi 11.

. M!+&!r a%an(an (!u u%an (u"i . K"i!n )a&a $!r&ar isi&asi )a"a+ u&a2a &!n0!ga%an "u(a !(anan &a)a saa $!ru$a% &osisi 5.. Eaga (!$!rsi%an (u"i )an %in)ari rau+a* &anas !r%a)a& (u"i (a&i"!r 5. O$s!r#asi !r%a)a& !ri !+a )an (!&u0a an )!ngan &a"&asi ar!a s!(i ar )an i)!n i'i(asi (!%anga an )an &!"una(an jaringan ia& +!ngu$a% &osisi 6. Hanga )an &!"una(an a)a"a% ana (!rusa(an jaringan 6.

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