C. INTERVENSI NO DIAGNOSA 1. Perubahan perfus !

ar n"an serebra# berhubun"an $en"an n%erups a# ran $arah& "an""uan '(#us f& he)'ra" & *as'spas)e serebra#& e$e)a serebra# $ %an$a $en"an DS+ , , Pas en )en"a%a(an pus n"& Pas en )en"a%a(an (epa#an-a %erasa sa( %& n-er $ ba" an (epa#a $en"an s(a#a n-er .,/ $ar 0,10 s(a#a n-er -an" $ ber (an& n-er seper% %er%e(an ben$a bera%. TUJUAN DAN KRITERIA HASIL Se%e#ah $ #a(u(an asuhan (epera1a%an $ harap(an perfus !ar n"an serebra# $apa% %er2apa se2ara 'p% )a# $en"an 2r %er a has # + 1. K# en % $a( "e# sah 3. T $a( a$a (e#uhan n-er (epa#a& )ua#& $an (e!an" 4. GCS 5&6&7 5. Tan$a,%an$a * %a# n'r)a# 8na$ 70, 1009:)n%& RR17, 309:)n%; INTERVENSI <an$ r + 1. Ka! fa2%'r -an" berhubun"an $en"an pen-ebab (husus se#a)a penurunan perfus serebra# $an p'%ens a# %er!a$ n-a pen n"(a%an TIK. 1. <e)pen"aruh pene%apan n%er*ens se#an!u%n-a. Kerusa(an: (e)un$uran %an$a neur'#'" s a%au (e"a"a#an )e)perba ( n-a pa$a fase a1a# )e)er#u(an % n$a(an pe)be$ahan a%au pas en harus $ p n$ah(an (eruan" pera1a%an (r % s 8ICU; un%u( )e#a(u(an pe)an%auan %erha$ap pen n"(a%an TIK. 3. <en"e%ahu (e2en$run"an % n"(a% (esa$aran $an pen n"(a%an TIK $an )en"e%ahu #'(as & #uas& $an res'#us (erusa(an SSP. Dapa% )enun!u((an TIA -an" )erupa(an %an$a %er!a$ n-a %hr')b's s CVS baru. 4. <e)an%au %an$a,%an$a * %a#+ , Var as )un"( n %er!a$ '#eh (arena %e(anan a%au %rau)a serebra# pa$a $aerah *as')'%'r '%a(. RASIONAL

3. Pan%au s%a%us neur'#'" s )e#a#u pen #a an GCS seser n" )un"( n.

DO+ , Tan$a,%an$a * %a#

4. Pan%au %an$a,%an$a * %a#& seper% + , A$an-a h per%ens :h p'%ens & ban$ n"(an %e(anan $arah

Te(anan Darah =130:>0& Na$ = 1009:)en %& RR =359:)en %& Pas en %a)pa( )er n" s& GCS 4&4&1&

-an" %erba2a pa$a (e$ua #en"an ?re(uens $an ra)a !an%un"& ser%a aus(u#%as a$an-a )ur)ur Ca%a% p'#a $an ra)a pernafasan

H per%ens a%au h p'%ens p's%ura# $apa% )en!a$ fa2%'r pen2e%us. H p'%ens $apa% %er!a$ (arena s-'( 8('#aps s r(u#as *as(u#er;. Pen n"(a%an TIK $apa% %er!a$ 8(arena '$e)a& a$an-a f'r)as be(uan $arah;. Tersu)ba%n-a ar%er sub(#a* a $apa% $ n-a%a(an $en"an a$an-a perbe$aan %e(anan $arah pa$a (e$ua #en"an. Perubahan %eru%a)a a$an-a bra$ (ar$ $apa% %er!a$ seba"a a( ba% a$an-a (erusa(an '%a(. D sr %) a $an )ur)ur )un"( n )en2er) n(an a$an-a pen-a( % !an%un" -an" )en!a$ pen2e%us s%'(e. Ke% $a(%era%uran pernafasan $apa% )e)ber (an "a)baran #'(as (erusa(an serebra# a%au pen n"(a%an TIK $an (ebu%uhan un%u( n%er*ens se#an!u%n-a %er)asu( (e)un"( naan per#un-a

5. Le%a((an (epa#a $en"an p's s a"a( $ % n"" (an $an $a#a)p's s ana%') s 8ne%ra#;.

5.

6. Per%ahan(an (ea$aan % rah 6. bar n"& 2 p%a(an # n"(un"an -an" %enan"& ba%as pen"un!un":a(% * %as pas en sesua n$ (as . @er (an s% raha% se2ara per '$ 2 an%ara a(% * %as pera1a%an& ba%as #a)an-a se% ap pr'se$ur. 7. Ce"ah %er!a$ n-a )en"e!an saa% 7. $efe(as & $an pernafasan -an" )e)a(sa 8ba%u( %erus, )enerus;. .. Ka! r " $ %as nu(a#& (e$u%an& .. (e"e# sahan -an" )en n"(a%& pe(a ran"san" $an seran"an (e!an". K'#ab'ras + >. Da#a) pe)ber an an% ('a"u#as & seper% na%r u) 1arfar n 8C'u)a$ n;& an% %r')b's % 8ASA;& $ pr $a)'# 8Persan% ne;. >.

$u(un"an un%u(pernafasan. <enurun(an %e(anan ar%er $en"an )en n"(a%(an $ra nase $an )en n"(a%(an s r(u#as a%au perfus serebra#. A(% * %as:s% )u#as -an" ('n% nu $apa% )en n"(a%(an TIK. Is% raha% %'%a# $an (e%enan"an )un"( n $ per#u(an un%u( pen2e"ahan %erha$ap per$arahan $a#a) (asus s%r'(e he)'ra" (:per$arahan #a nn-a. <anu*er Va#sa*a $apa% )en n"(a%(an TIK $an )e)perbesar res (' %er!a$ n-a per$arahan. <erupa(an n$ (as a$an-a r %as )en n"ea#. Ke!an" $apa% )en2er) n(an a$an-a pen n"(a%an TIK: %rau)a serebra# -an" )e)er#u(an perha% an $an n%er*ens se#an!u%n-a. Dapa% $ "una(an un%u( )en n"(a%(an:)e)perba ( a# ran $arah serebra# $an se#an!u%n-a $apa% )en2e"ah pe)be(uan saan

/. Pe)ber an An% f br'# % (& seper% asa) a) n'(apr' $ 8A) 2ar;

10. Pe)ber an an% h per%ens

11. Pe)ber an *as'$ #a%as per fer& seper% s (#an$e#a% 8C-2#'spas)'#;& papa*er n 8pa*ab $:*as'span;& s'(supres n 8Vas'$ #an; 3. Kerusa(an )'b # %as f s ( berhubun"an $en"an (erusa(an fun"s neur'#'" s& he) p#e" 2 Se%e#ah $ #a(u(an asuhan (epera1a%an $ harap(an )'b # %as f s ( )en"a#a) pen n"(a%an $en"an 2r %er a has # + 1. K# en % $a( )en"a#a) <an$ r + 1. Ka! (e)a)puan se2ara fun"s 'na# a%au #uasn-a (erusa(an a1a# se2ara %era%ur 3. A!ar(an #a% han ren%an" "era(

e)b'#us:%hr')bus )erupa(an fa2%'r e% '#'" n-a. /. Pen""unaan $en"an ha% ,ha% $a#a) per$arahan un%u( )en2e"ah # s s be(uan -an" %erben%u( $an per$arahan beru#an" serupa 10. H per%ens #a)a:(r'n s )e)er#u(an penan"anan -an" ha% ,ha% & sebab penan"anan -an" ber#eb han )en n"(a%(an res (' %er!a$ n-a per#uasan (erusa(an !ar n"an. H per%ens se)en%ara ser n" (a# %er!a$ se#a) fase s%r'(e a(u% $an penan"u#an"ann-a ser n" (a# %anpa n%er*ens %erapeu% (. 11. D "una(an un%u( )e)perba ( s r(u#as ('#a%era# a%au )enurun(an *as'spas)e

1. <en" $en% f (as (e(ua%an:(e#e)ahan $an $apa% )e)ber (an nf'r)as )en"ena pe)u# han. @an%u

$ %an$a $en"an+ DS+ Pas en )en"a%a(an su# % )en""era((an ba$ann-a Pas en )en"a%a(an % $a( )a)pu )e#a(u(an a(% * %asn-a DO+ Pas en %a)pa( % $a( )a)pu bera(% * %as Ta)pa( (e#e)ahan pa$a e(s%re) %as A(% * %as pas en %a)pa( $ ban%u '#eh (e#uar"an-a Ke(ua%an '%'% )enurun

('n%ra(%ur '%'%

a(% f $an pas f pa$a se)ua e(s%er) %as se2ara ber%ahap. An!ur(an )e#a(u(an #a% han seper% )ere)as b'#a (are%& )e#ebar(an !ar ,!ar $an (a( a%au %e#apa(. 4. Te)pa%(an ban%a# $ ba1ah a(s #a un%u( )e#a(u(an ab$u(s pa$a %an"an. 5. @an%u % n"" (an %an"an pas en. 6. Te)pa%(an Ahar$ r'##B (eras pa$a %e#apa( %an"an $en"an bu !ar $an !ar ,!ar sa# n" berha$apan. 7. P's s (an #u%u% $an pan""u# $a#a) p's s e(s%ens . .. Per%ahan(an (a( pa$a p's s ne%ra# $en"an "u#un"an a%au ban%a#an %r'(an%er. >. Guna(an papan (a( se2ara ber"an% & ! (a )e)un"( n(an. /. @an%u un%u( )en"e)ban"(an (ese )ban"an $u$u( $an (ese )ban"an $a#a) ber$ r . 10. Obser*as $aerah -an" %er(ena %er)asu( 1arna& '$e)a& a%au %an$a #a n $ar "an""uan s r(u#as . 11. @an"un(an $ar (urs sese"era

3.

4. 5.

6.

7. .. >.

$a#a) pe) # han %erha$ap n%er*ens . <e) n )a#(an a%r'f '%'%& )en n"(a%(an s r(u#as & )e)ban%u )en2e"ah ('n%ra(%ur. <enurun(an res (' %er!a$ n-a h per(as ur a $an 's%e'p'r's s ! (a )asa#ah u%a)an-a a$a#ah per$arahan. <en2e"ah a$$u(s bahu $an f#e(s s (u. <en n"(a%(an a# ran ba# ( *ena $an )e)ban%u )en2e"ah %erben%u(n-a '$e)a. A#as:$asar -an" (eras )enurun(an s% )u#as f#e(s !ar ,!ar & )e)per%ahan(an !ar , !ar $an bu !ar pa$a p's s n'r)a# 8p's s ana%') s;. <e)per%ahan(an p's s fun"s 'na#. <en2e"ah r'%as e(s%erna# pa$a p n""u#. Pen""unaan -an" 2'n% nu $apa% )en-ebab(an %e(anan -an" ber#eb han pa$a sen$ pe#uru (a( & )en n"(a%(an spas% s %as& $an se2ara n-a%a )en n"(a%(an f#e(s p#an%ar.

)un"( n se%e#ah %an$a,%an$a * %a# s%ab # (e2ua# pa$a he)'ra" ( serebra#. 13. A#as (urs $u$u( $en"an busa a%au ba#'n a r $an ban%u pas en un%u( )e) n$ah(an bera% ba$an $en"an n%er*a# -an" %era%ur. 14. A!ar(an (e#uar"a a%au 'ran" %er$e(a% $a#a) a(% * %as:#a% han $an )en"ubah p's s 15. An!ur(an pas en un%u( )e)ban%u per"era(an $an #a% han $en"an )en""una(an e(s%er) %as -an" % $a( sa( % un%u( )en-'('n":)en""era((an ba" an %ubuh -an" )en"a#a) (e#e)ahan. K'#ab'ras 16. K'nsu#%as (an $en"an ah# f s '%erap se2ara a(% f& #a% han res s% f& $an a)bu#as pas en. 17. @an%u )en""una(an s% )u#as e#e(%r (& seper% TENS sesua n$ (as . 1.. @er (an 'ba% re#a(san '%'%& an% spas)'$ 2 sesua n$ (as

/. <e)ban%u $an )e#a% h (e)ba# !aras saraf& )en n"(a%(an resp'n pr'pr 'sep% ( $an )'%'r (. 10. Jar n"an -an" )en"a#a) '$e)a #eb h )u$ah )en"a#a) %rau)a $an pen-e)buhan -an" #a)ba%. 11. <e)ban%u )ens%ab #(an %e(anan $ara& )en n"(a%(an (ese )ban"an e(s%er) %as $a#a) p's s n'r)a#. 13. <en2e"ah:)enurun(an %e(anan ('s "ea#. 14. <en n"(a%(an harapan %erha$ap per(e)ban"an: pen n"(a%an $an )e)ber (a perasaan 2'n%r'#:(e)an$ r an. 15. Dapa% beresp'n $en"an ba ( ! (a $aerah -an" sa( % % $a( )en!a$ #eb h %er"an""u $an )e)er#u(an $'r'n"an ser%a #a% han a(% f un%u( )e)per2epa% pe)u# han. 16. Pr'"ra) -an" (husus $apa% $ (e)ban"(an un%u( )ene)u(an (ebu%uhan %erap pas en $a#a) (ese )ban"an& (''r$ nas $an (e(ua%an.

8ba(#'fen& $a%r'#en;.

4.

Res (' % n"" %erha$ap 2e$era berhubun"an $en"an $ef s % #apan" pan$an" )'%'r ( a%au perseps $an (e#e)ahan fs( N-er a(u% behubun"an $en"an pen n"(a%an TIK $ %an$a $en"an DS+ pas en )en"a%a(an n-er $ $aerah (epa#an-a& n-er $ rasa(an seper% %er%e(an ben$a bera%& s(a# n-er bera% .,/ $ar 10 s(a#a n-er -an" $ ber (an.

Se%e#ah $ #a(u(an asuhan (epera1a%an $ harap(an % $a( %er!a$ 2e$era $en"an 2r %er a has # + 1. T $a( %er!a$ 2e$era 3. T $a( %er$apa% #u(a Se%e#ah $ #a(u(an asuhan (epera1a%an $ harap(an n-er ber(uran" $en"an 2r %er a has # + 1. N-er h #an" a%au ber(uran" saa% bera(% * %as. 3. S(a#a n-er 0 $ar 0,10 s(a#a n-er -an" $ ber (an 4. Ca!ah pas en %a)pa( %enan" 5. Tan$a,%an$a V %a# (e)ba# n'r)a#+ TD + 100,130 : 70,>0

1. Pasan" pa"ar %e)pa% % $ur 3. Guna(an 2aha-a -an" 2u(up

17. Dapa% )e)ban%u )e)u# h(an (e(ua%an '%'% $an )en n"(a%(an 2'n%r'# '%'% *'#un%eer. 1.. D per#u(an un%u( )en"h #an"(an spas% s %as pa$a e(s%er) %as -an" %er"an""u. 1. Pa"ar %e)pa% % $ur )e# n$un" (# en a"ar % $a( %er!a%uh $ar %e)pa% % $ur 3. Gan""uan * sua# )en n"(a%(an res (' %rau)a pa$a (# en 1. <en"e*a#uas %erap -an" $ ber (an $an )e)ban%u )enen%u(an % n$a(an se#an!u%n-a. 3. Un%u( )en"e%ahu (ea$aan u)u) pas en 4. Is% raha% -an" 2u(up $apa% )en n"(a%(an perasaan r #e(s pa$a pas en 5. Un%u( )e)ber (an rasa n-a)an (epa$a pas en

5.

<an$ r <an$ r + 1. Ka! s(a#a& #'(as & $an fa(%'r -an" )e)perbera% a%au )er n"an(an n-er . 3. Obser*as TTV 4. @er (an 1a(%u s% raha% -an" 2u(up. 5. @er (an (')pres $ n" n sesua n$ (as

))H" N + 70,100 (a# :)en % DO+ pas en %a)pa( )e)e"an" $aerah (epa#an-a& pas en %a)pa( )er n" s& %an$a,%an$a * %a# pas en $ a%as n'r)a# 8TD+ = 130:>0))H"& Na$ = 1009:)en %& RR = 359:)n%& S = 4.&6 C; S + 47&6 D 4.&5 C RR + 17 D 35 9:)en %

6. An!ur(an %e(n ( $ s%ra(s $an re#a(sas K'#ab'ras + 7. @er (an 'ba% ana#"e% ( sesua $en"an pr'"ra) %erap .

6. D s%ra(s $an re#a(sas & $apa% )en"uran" rasa n-er pas en

7. Ana#"e% ( )e)ban%u )en"uran" rasa n-er

6.

Perubahan nu%r s (uran" $ar (ebu%uhan %ubuh

Se%e#ah $ #a(u(an asuhan (epera1a%an $ harap(an nu%r s

1.

Sebe#u) )a(an& (a!

)e)ber (an 1. <en"e%ahu (e)a)puan apa(ah pas en pas en $an (e)un"( nan

berhubun"an $en"an (e% $a()a)puan )ene#an se(un$er %erha$ap para# s s $ %an$a $en"an& DS+ Pas en )en"a%a(an )ua#& (e#uar"a pas en )en"a%a(an pas en )un%ah = 49 sehar & pas en )en"a%a(an susah )ene#an $an )en"un-ah )a(anann-a. DO+ pas en han-a )en"hab s(an 1:4 $ar 1 p r n" -an" $ ber (an& pas en %a)pa( (urus& pas en %a)pa( #e)ah& bera% ba$an pas en %urun 6 ("& # n"(ar #en"an 30 2)

pas en )en"a#a) pen n"(a%an $en"an 2r %er a has # + , bera% ba$an pas en )en n"(a% , # n"(ar #en"an pas en N #a N'r)a# + 37&4 2) un%u( #a( ,#a( 36&. 2) un%u( 1an %a , pas en % $a( )ua# $an )un%ah , pas en )en"hab s(an 1 p'rs )a(an -an" $ ber (an

3.

4. 5.

6. 7.

..

>.

/.

2u(up sa$ar $an resp'ns f& apa(ah $apa% )en"'n%r'# )u#u%& $apa% ba%u( $an $apa% )ene#an sa# *an-a sen$ r . T n"(a%(an upa-a un%u( $apa% )e#a(u(an pr'ses )ene#an -an" efe(% f $en"an 2ara )e)ban%u pas en un%u( )en"'n%r'# (epa#a. An!ur(an pas en un%u( s% raha% sebe#u) )a(an. @er (an )a(an $en"an per#ahan pa$a # n"(un"an -an" %enan". @er (an )a(anan $a#a) p'rs se$ ( % %e%ap ser n". @er (an )a(anan $en"an ('ns s%ens se%en"ah 2a r a%au #una(. @er (an )a(anan %a)bahan 8) s. A"ar,a"ar;& b #a % $a( a$a ('n%ra n$ (as . U(ur bera% ba$an& # n"(ar #en"an $an # n"(ar peru% pas en. K'#ab'ras $en"an $'(%er $a#a) pen""unaan nas'"as%r 2 %ube apab #a pas en % $a( )a)pu un%u( )ene#an.

(erusa(an $a#a) )enen%u(an p # han n%er*ens )e)ber (an nu%r s :p # han ru%e )a(an -an" %epa% -an" a(an $ "una(an. 3. <ene%ra#(an h pere(s%ens & )e)ban%u )en2e"ah asp ras $an )en n"(a%(an (e)a)puan un%u( )ene#an. <en"uran" (e#e#ahan '%'% seh n""a %er!a$ pen n"(a%an ener" saa% )a(an seh n""a )en"uran" res (' %erse$a(. Pas en $apa% ber('nsen%ras pa$a )e(an s)e )a(an %anpa a$an-a "an""uan $ar #uar. )en"uran" rasa )ua# $an )un%ah. <a(anan #una(:se%en"ah 2a r #eb h )u$ah $ %e#an $an )en"uran" res (' asp ras . <en""u"ah se#era )a(an $an )en n"(a%(an asupan nu%r s . )en"e%ahu per(e)ban"an pen n"(a%an bera% ba$an& # n"(ar #en"an& # n"(ar peru%. Pe)asan"an $an pen""unaan nas'"as%r 2 %ube

4.

5.

6. 7.

..

>.

/.

10.

K'#ab'ras $en"an ah# " E $a#a) )e)ber (an $ e% % n"" (a#'r % n"" pr'%e n& $an % n"" sera%. 11. K'#ab'ras $en"an $'(%er $a#a) pe)ber an )u#% * %a) n

7.

Kerusa(an (')un (as *erba# berhubun"an $en"an efe( (erusa(an pa$a he) sfer bahasa a%au 1 2ara 8( r a%au (anan; DS+ , Pas en b 2ara %erba%a,ba%a Ke#uar"a pas en )en"a%a(an pas en susah un%u( berb 2ara& DO+ , pas en %a)pa( susah

Se%e#ah $ #a(u(an asuhan (epera1a%an $ harap(an (erusa(an (')un (as *erba# %era%as $en"an 2r %er a has # + , pas en %er# ha% )en"a#a) pen n"(a%an berb 2ara , pas en $apa% )en"a%a(an beberapa (a%a $en"an !e#as

1.

3.

4.

5.

$apa% )e)ban%u )e)enuh asupan nu%r s pas en -an" )e) # ( )asa#ah )ene#an. 10. <a(anan % n"" (a#'r % n"" pr'%e n $apa% )en n"(a%(an ener" pas en. <a(anan % n"" sera% $apa% )en n"(a%(an per s%a#% ( usus& )en2e"ah ('ns% pas . 11. Pe)ber an )u#% * %a) n un%u( )ena)bah asupan nu%r s : * %a) n. (a! 1. )enen%u(an $era!a% % pe:$era!a% $ sfun"s & seper% (erusa(an serebra# -an" %er!a$ pas en % $a( %a)pa( )e)aha) $an (esu# %an $a#a) beberapa (a%a a%au )en"a#a) (esu# %an a%au se#uruh %ahap pr'ses berb 2ara a%au )e)bua% (')un (as . Pas en )un"( n pen"er% an sen$ r . )e)pun-a (esu# %an D'r'n" )e)aha) (a%a -an" n$ * $u un%u( )enun!u( $an $ u2ap(an a%au )en"u2ap(an )en""una(an bahasa %ubuh $an (a%a,(a%a $en"an benar. pan%') ). 3. @ahasa %ubuh $an pan%') n An!ur(an seba"a (')un (as n'n*erba# (# en n%u( )en"u2ap(an (a%a, $apa% )en" s-ara%(an (ea$aan (a%a se2ara ha% ,ha% $an $an (ebu%uhan -an" per#ahan $en"an "era(an b b r $ bu%uh(an pas en. -an" !e#as. 4. A"ar pera1a%:(e#uar"a @ 2ara#ah #eb h )en"er% $en"an apa -an" $an a!ar(an (e#uar"a pas en $ (a%a(an (# en $an

)en"e#uar(an suara $an pas en %a)pa( berb 2ara %erba%a,ba%a

berb 2ara $en"an na$a n'r)a# $an h n$ar per2a(apan -an" 2epa%. 6. @er (an pas en !ara( $an 1a(%u un%u( berb 2ara saa% beresp'n 7. An!ur(an 'ran" %er$e(a%:(e#uar"a )e)per%ahan(an ber(')un (as $en"an pas en. .. Tun$a per2a(apan ! (a (# en #e#ah.

5.

6.

7.

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)en"uran" pen"e#uaran ener" pas en. A"ar pas en $apa% )en"er% (a%a,(a%a -an" $ u2ap(an pera1a% )aupun (e#uar"an-a. <e)f'(us(an resp'n pas en %erha$ap apa -an" n" n $ u2ap(an. <en"uran" s'#as s's a# pas en $an )en n"(a%(an pen2 p%aan (')un (as -an" efe(% f. K# en )e) # ( (e%erba%asan $a#a) berb 2ara a( ba% (e#e)ahan '%'%& )enun$a per2a(apan a(an )e)ber (an (ese)pa%an un%u( )en" s% raha%(an $an )en"e)ba# (an '%'%,'%'% ban%u berb 2ara.

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Perubahan perseps sens'r berhubun"an $en"an s%res ps ('#'" s 8pen-e)p %an #apan" persep%ua# -an" $ sebab(an '#eh ans e%as; DS+ , Pas en

Se%e#ah $ #a(u(an asuhan 1. Ka! a$an-a "an""uan (epera1a%an $ harap(an pen"# ha%an. Ca%a% a$an-a perseps sens'r )en"a#a) penurunan #apan" pan$an"& pen n"(a%an $en"an 2r %er a perubahan (e%a!a)an perseps . has # + 3. Ka! (ea$aan sens'r (& , pas en $apa% )erasa(an seper% )e)be$a(an ar')a& s% )u#as -an" $ ber (an panas:$ n" n& %a!a):%u)pu#& p's s ba" an %ubuh:'%'%& rasa

1.

<un2u#n-a "an""uan pen"# ha%an $apa% ber$a)pa( ne"a% *e %erha$ap (e)a)puan pas en un%u( )ener )a # n"(un"an $an )e)pe#a!ar (e)ba# (e%ra)p #an )'%'r (. 3. Penurunan (esa$aran %erha$ap sens'r ( $an

)en"a%a(an % $a( )erasa(an sen%uhan saa% $ ber (an s% )u#as DO+ , pas en %a)pa( % $a( %erpen"aruh %erha$ap s% )u#as

persen$ an. 4. De(a% pas en $ar $aerah pen"# ha%an -an" n'r)a#. 5. @er (an s% )u#as %erha$ap rasa sen%uhan seper% ber (an pas en sua%u ben$a. 6. @er (an # n"(un"an -an" a)an $an n-a)an.

>.

Def s % pera1a%an $ r berhubun"an $en"an "an""uan )'b # %as f s ( $an "an""uan pr'ses ('"n % f DS+ , Ke#uar"a pas en )en"a%a(an su$ah % $a( pernah

Se%e#ah $ #a(u(an asuhan 1. Ka! (e)a)puan $an (epera1a%an $ harap(an % n"(a% (e(uran"an pas en pera1a%an $ r pas en 8$en"an )en""una(an s(a#a 0, )en n"(a% $en"an 2r %er a has # 5; un%u( berpar% s pas $a#a) + a(% f %as pera1a%an $ r . Kebu%uhan pera1a%an $ r 3. @an%u pera1a%an $ r pas en 'p% )a# 8)an$ 39 sehar $en"an $ #ap& Ku# % %a)pa( % $a( ('%'r& (era)as 3 har se(a# ! (a % $a( <u#u% pas en % $a( bau& a$a ('n%ra n$ (as ;.

(erusa(an perasaan ( ne% 2 berpen"aruh buru( %erha$ap (ese )ban"an:p's s %ubuh $an (esesua an $ar "era(an -an" )en""an""u a)bu#as & $an $apa% )en n"(a%(an res (' %rau)a. 4. Pe)ber an pen"ena#an %erha$ap a$an-a 'ran":ben$a $apa% )e)ban%u )asa#ah perseps $an )en2e"ah (e%er(e!u%an pas en. 5. <e)ban%u )e#a% h (e)ba# !aras sens'r ( un%u( )en" n%e"ras (an perseps $an n%erpre%as s% )u#as . 6. Dapa% )enurun(an res (' %rau)a& ans e%as&$an resp'ns e)'s -an" ber#eb han:(eb n"un"an. 1. K'n$ s $asar a(an )enen%u(an % n"(a% (e(uran"an : (ebu%uhan pe)enuhan se2ara n$ * $ua#. 3. <en!a"a $an )en n"(a%(an (ebers han pas en. 4. <e)enuh (ebu%uhan %' #e% n"

)an$ (e (a)ar )an$ $an han-a $ #ap sehar se(a# & Ke#uar"a pas en )en"a%a(an pas en % $a( pernah )en""'s'( " " . DO+ , Pas en %a)pa( ('%'r& bau ba$an& ra)bu% (usu%& (u# % %a)pa( ('%'r& bau )u#u%& " " ('%'r& ADL pas en %a)pa( $ ban%u (e#uar"a.

G " pas en %a)pa( #eb h bers h& Ra)bu% %er# ha% rap .

4.

@er (an a#a% ban%u -an" $ per#u(an un%u( %' #e% n" 8ur na#& be$pan;. 5. @er (an (ese)pa%an un%u( (ebers han 'ra#. 6. @er (an #'% 'n:%a#( se%e#ah )e)bers h(an $ r . 7. A!ar(an (e)an$ r an pas en $a#a) )e)bu(a (an2 n"& a%aupun )e#epas pa(a an se2ara ber%ahap& na)un % $a( $ pa(sa(an ! (a ('n$ s pas en buru(.

$en"an (e)anan -an" 'p% )a#. 5. )en!a"a (ebers han )u#u%. 6. <en"h n$ar $e(ub %us a( ba% % rah bar n" -an" #a)a. 7. <e#a% h (e)an$ r an $a#a) pe)enuhan ADL.

/.

Gan""uan har"a $ r berhubun"an $en"an b 'f s (& ps ('s's a#& persep%ua# ('"n % f. DS+ , Ke#uar"a pas en )en"a%a(an pas en )a#u $en"an (ea$aan-a. Pas en !aran" ber n%era(s $en"an # n"(un"an se( %ar.

Se%e#ah $ #a(u(an asuhan (epera1a%an $ harap(an har"a $ r pas en )en n"(a% $en"an 2r %er a has # + Pas en % $a( )a#u $en"an (ea$aan K'n%a( )a%a 8F; Pas en $apa% ber n%era(s $en"an # n"(un"an se( %ar 8'ran" %er$e(a%& pera1a%& $'(%er& % ) (eseha%an #a n;

1.

Ka! "an""uan perseps $an hubun"(an $en"an $era!a% (e% $a()a)puann-a. 3. I$en% f (as )a(na $ar (eh #an"an:perubahan har"a $ r pa$a pas en. 4. Te(an(an (eberhas #an -an" (e2 # se(a# pun ba ( )en"ena pen-e)buhan fun"s %ubuh a%aupun (e)an$ r an pas en. 5. An!ur(an 'ran"

1.

Penen%uan fa2%'r -an" $apa% )e)ban%u )en"e)ban"(an n%er*ens -an" a(an $ p # h. 3. <enun!u((an )a(na pener )aan $ r )aupun (e)un$uran %erha$ap perubahan $ r n-a $an 2ara )en"a%as perubahan %ersebu% se2ara efe(% f. @eberapa pas en )en"a#a) (esu# %an $a#a) )ener )a $an )n"a%as

DO+ , Pas en %a)pa( !aran" berb 2ara apab #a % $a( $ a!a(. K'n%a( )a%a 8,;.

%er$e(a%:(e#uar"a )e)per%ahan(an ber(')un (as $en"an pas en.

10.

Res (' % n"" (erusa(an n%e"r %as (u# %

Se%e#ah $ #a(u(an asuhan (epera1a%an $ harap(an % $a( %er!a$ (erusa(an n%e"r %as Ds + (u# % $en"an 2r %er a has # + , Pas en 1. Pas en $apa% )en"a%a(an se#a)a berpar% s pas %erha$ap sa( % han-a berbar n" pen2e"ahan #u(a $ %e)pa% % $ur 3. Pas en )en"e%ahu D' + pen-ebab $an 2ara - Pas en )en"a#a) pen2e"ahan #u(a& % $a( % rah bar n" -an" a$a %an$a,%an$a #a)a (e)erahan a%au #u(a& (u# % (er n"

1. Obser*as %erha$ap er %e)a $an (epu2a%an. Pa#pas area se( %ar %erha$ap (ehan"a%an $an pe#una(an !ar n"an se% ap )en"ubah p's s 3. An!ur(an un%u( )e#a(u(an #a% han RO< $an )'b # sas ! (a )un"( n 4. Ubah p's s % ap 3 !a).

(e(uran"ann-a. 4. <en"('ns'# $as (an (eberhas #an $apa% )e)ban%u )enurun(an perasaan (e% $a(ber$a-aan pa$a pas en $an )en )bu#a(n perasaan a$an-a per(e)ban"an. 5. <en"uran" penurunan har"a $ r pas en $an )en n"(a%(an pen2 p%aan (')un (as -an" efe(% f. 1. Han"a% $an pe#una(an a$a#ah %an$a (erusa(an !ar n"an

5. Guna(an ban%a# a r a%au pen""an!a# -an" #una( $ ba1ah $aerah,$aerah 8%u#an"; -an" )en'n!'# 6. La(u(an )asase pa$a $aerah 8%u#an"; -an" )en'n!'# -an" )en"a#a) %e(anan pa$a 1a(%u

3. <en n"(a%(an a# ran $arah (e se#uruh %ubuh 4. <en"h n$ar %e(anan $an )en n"(a%(an a# ran $arah. 5. <en"h n$ar %e(anan -an" ber#eb h pa$a $aerah 8%u#an"; -an" )en'n!'# 6. <en"h n$ar (erusa(an, (erusa(an (ap #er 7. <en n"(a%(an n%e"r %as (u# % $an )en"uran" res (' (e#e)bapan (u# %.

berubah p's s 7. @ers h(an $an (er n"(an (u# %. Ja"a#ah %enun %e%ap (er n". .. Ja"a (ebers han (u# %& se) n )a# )un"( n h n$ar %rau)a $an panas %erha$ap (u# % 11. Kuran" pen"e%ahuan berhubun"an $en"an (uran" nf'r)as & (e%erba%asan ('"n % f& (uran" )en" n"a%& % $a( )en"ena# su)ber $an nf'r)as . Ds + - Ke#uar"a )en"a%a(an % $a( )en"er% %en%an" pen-a( % pas en D' + - Ke#uar"a %er# ha% ber%an-a,%an-a %en%an" pen-a( %n-a - Ke#uar"a %a)pa( b n"un" Se%e#ah $ #a(u(an asuhan (epera1a%an $ harap(an pas en )en"er% %en%an" pen-a( %n-a $en"an 2r %er a has # + 1. Ke#uar"a % $a( %a)pa( b n"un" #a" 3. Ke#uar"a )en-a%a(an pe)aha)an %erha$ap ('n$ s & pr'"n's s pen-a( %& $an (ebu%uhan pen"'ba%an pas en

.. <e)per%ahan(an (eu%uhan (u# %.

1. @er (an nf'r)as -an" %epa% 1. <ena)bah )en"ena ('n$ s & pr'"n's s nf'r)as pa$a (e#uar"a pen-a( %& $an (ebu%uhan )en"ena ('n$ s & pr'"n's s pen"'ba%an. pen-a( %& $an (ebu%uhan pen"'ba%an pas en 3. Ka! % n"(a% pe)aha)an (e#uar"a %erha$ap ('n$ s & pr'"n's s pen-a( %& $an 3. <en"e*a#uas (ebu%uhan pen"'ba%an (eberas #an pe)ber an nf'r)as

13.

Se%e#ah $ ber (an asuhan (epera1a%an $ harap(an ans e%as %era%as $en"an (r %er a has # + Ds + - Ke#uar"a pas en % $a( - Ke#uar"a )en"a%a(an %a)pa( 2e)as $an 2e)as $en"an "e# sah (ea$aan pen-a( % - Ke#uar"a pas en pas en %a)pa( r #e(s D' + - Ke#uar"a pas en %a)pa( 2e)as - Ke#uar"a pas en %a)pa( "e# sah

Ans e%as berhubun"an $en"an pr'"n's s pen-a( % pas en

1. Se#a#u a$a un%u( (e#uar"a pas en 3. @ na hubun"an sa# n" per2a-a $en"an 'ran" %er$e(a%. 4. Per%ahan(an pr #a(u n-a%a $a#a) )e#a(u(an pr'se$ur : )ener )a pas en& # n$un" pr *a2- pas en. 5. @er pen"ua%an nf'r)as pa$a (e#uar"a -an" %e#ah $ ber (an sebe#u)n-a.

1.

3. 4.

5.

<enun!u((an perha% an $an (e n" nan un%u( )e)ban%u )enurun(an (e2e)asan pas en. <e)ban%u $a#a) $ s(us %en%an" sub-e( sens % *e. <e)ber (an rasa n-a)an pa$a pas en $a#a) )e)ber (an asuhan (epera1a%an <e)un"( n(an pas en un%u( )ener )a (en-a%aan $an )en"ua%(an (eper2a-aan (epa$a pe)ber pera1a%an ser%a )en"h #an"(an (e2e)asan