Resume Kasus Keperawatan Vulnus Punctum Abdomen

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GEG CC

WD]TFD KE]T] KDRDWE^EQEH NE^EQ AEWTWEQ

Qn` Fesuk Wufel ]ekct 9 53 Iuhc 7251

Ief 9 57.=2 ^cte

Hjfjr Wdncstdr 9 52-21-52 Qeluh1. Kewch / Gd`uf Kewch 9 Gd`uf Kewch4. E n e f e 9 Cs`ef?. ]uku / Gehnse 9 Fekesser/Chajhdsce>. Rdhacackeh 9 ]FR

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=>

?. Rdhacackeh 9 ]FE>. Rdhaepeteh 9 7.222.222/Gu`eh

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=. Metet pdrugeleh peae ENA, ]eJ7, Mj7 gc`e acpdr`ukeh. (R) ^cteFdfpdrtelehkeh pjscsc pescdh

Lesc`9Rjscsc kdpe`e actchnnckeh 52 adreiet sdsuec kdhyefeheh pescdh

=. Ief 57.=< ^cteFdfehteu kdnd`cseleh aeh ehscdtes ekcget pdfesehneh jkscndh

Lesc`9 Qcaek eae tehae aeh `epjreh kdmdfeseh

1. Fjhctjr eaehye lypdrvdhtc`esc

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Lesc`9 tcaek tdr`clet tehae-tehae lcpdrvdhtc`esc ( gdrhepes mdpet adhneh

terckeh hepes ae`ef)

4. Ief 5=.72 ^cteFdfehteu kdmdpeteh, crefe, kdae`efeh, aeh upeye pdrhepeseh

Lesc`9 kdmdpeteh hepes 7< ke`c pdrfdhct, hepes aehnke`, tcaek tefpek

kdsu`cteh gdrhepes

?. Ief 5=.77 ^cteFdfdrletckeh pdrndrekeh aeae, efetc kdscfdtrcseh, pdhnnuheeh jtjt gehtu,

aeh rdtreksc suprek`evcku`er aeh chtdrmjste`

Lesc`9 Rdrndrekeh aeae scfdtrcs, tcaek eae pdhnnuheeh jtjt gehttu hepe,

tcaek eae rdtreksc chtdrmjste` aeh tcaek eae rdtreksc suprek`evcku`er

Dve`uesc 9

Qehnne` 53 Iuhc 7251 ief 5=.=2^cte

] 9K`cdh fdhnetekeh sdsek gdrkurehn

J 9Ordkudhsc Hepes 7< ke`c pdrfdhct

J7 tdrpesehn 1 @RF gchese`

E 9Fese`el Gd uf tdretesc

R 9@ehiutkeh chtdrvdhsc

Mcrmu`etcjh

Epekel eae pdraereleh/tcaek:Qcge ac CWA `uke ae`ef kdeaeeh accket fdhnnuhekeh kech, aerel

fdrdfgds kdseruhn pescdh.

Epekel eae pu`se kerjtcs, heac reace` :Heac reace` 521 ke`c pdrfdhct, kue`ctes heac kuet

Ekre` peae dkstrdfctes tdrege achnch Rdhncsceh kepc`dr kurehn aerc = adtck Epekel eae tehae-tehae syjk:

Qdraepet temlcmerac aeh temlyphdu

Epekel ku`ct tdrege achnch/lehnet:Ku`ct tdrege lehnet

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Epekel ku`ct tefpek pumet eteu kdgcru-gcrueh:Ku`ct tcaek tefek pumet, tcaek tefpek scehjscs

Epekel pescdh tcaek seaer eteu hefpek fdhnehtuk: Kdseaereh Mjfpjsfdhtcs, NM] 54 (D1_4F?)

Ac enhjse Kdpdreweteh 9

Wcsckj syjk

Oektjr yehn gdrluguhneh9Lcpjvj`dfce

Wdhmehe Qchaekeh 9

Quiueh9

sdtd`el ac`ekukeh tchaekeh kdpdreweteh sd`efe 5 ief aclerepkeh k`cdh ekeh

fdhuhiukkeh Meracpu`fjhery stetus (HJM) adhneh chacketjr9

Chacketjr ]ke`e

Qdkeheh aerel scstj`ck aeh acstj`ck

Heac pdrcodr

Crefe iehtuhn

Crefe hepes

werhe ku`ct

4

4

4

4

4

Kdtdrehneh ]ke`e

5. Nehnnueh dkstrdf

7. Nehnnueh gdret=. Nehnnueh sdaehn1. Nehnnueh rchneh4. Qcaek eae nehnnueh

C htdrvdhsc9

Ektcvctes kdpdreweteh9

]lyjk feheidfdh (HCM)

5. Fjhctjr tehae aeh ndie`e eaehye pdraereleh pdrscstdh ( R)7. Metet hc`ec LG aeh LQ (R)=. Gdrckeh prjauk aerel sdsuec chtruksc(C)1. Mdnel kdlc`ehneh aerel adhneh fdhdkeh scsc pdraereleh (K)Cfp`dfdhtesc 9

5. Ief 5=.=< ^cteFdhmetet hc`ec LG

Lesc`9LG 55,4%/a`

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7. Ief 5=.=< ^ctefdhmdnel kdlc`ehneh aerel adhneh fdhdkeh scsc pdraereleh

Lesc`9 tdrpesehn tefpjh peae uke

Dve`uesc 9

Qehnne` 53 Iuhc 7251 ief 51.=2

] 9 -

J 9 Heac 521 ke`c pdrfdhct

Kue`ctes heac kuet

Qdkeheh aerel 572/32 ffln

Kdseaereh mjfpjsfdhtcs, NM] 54

E 9 Fese`el gd`uf tdretesc

R 9 @ehiutkeh chtdrvdhsc 5-?

Acsegc`cty

K`cdh fdhndrtc epe yehn acketekeh pdrewet Rupc` gdrdeksc tdrleaep meleye, acefdtdr pupc` = mf, csjkjr scfdtrcs keheh

aeh kcrc

NM] (N`esnjw Mjfe ]me`d) 54 (D1F4_?)A. ]urvdy ]dkuhadr

5. EFR@De. E``drncds(e`drnc) 9

K`cdh fdhnetekeh tcaek eae rcweyet e``drnc fekeheh aeh jget-jgeteh

g. Fdacmetcjh (jget-jgeteh) 9Rescdh fdhnetekeh gd uf pdrhel fdhaepetkeh jget epepuh sdtd`el

Kdmd`ekeeh

m. Rest lcstjry (rcweyet schnket pdhyekct, kdmd`ekeeh, tchaekeh pdfgdaeleh,aeh pdreweteh sd`efe sekct). 9

Rescdh fdhnetekeh tcaek pdrhel acrewet ac Wufel sekct sdgd`ufhye

a. @est tcfd etd jr arehk (wektu tdreklcr fekeh aeh fchuf) 9Rescdh fdhnetekeh tdreklcr serepeh penc ief 23.22 wcte, fchuf 1 ief

]FW]

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d. Dvdht (epe yehn fdhydgegkeh tdrieachye kdmd`ekeeh: Kdmd`ekeehkdhaereeh, `uke geker, a`` 9

Rescdh fdhnetekeh acleaehn j`dl jrehn tcaek ackdhe` seet pu`ehn sdkj`el

, seet fd`ekukeh pdr`eweheh pescdh actusuk fdhnnuhekeh gdhae teief,

kdfuaceh acterck aeh pd`eku fd`erckeh acrc, sdseet sdtd`el kdieaceh pescdh

acgewe kd CNA W]TC Oecse` Fekesser

7. Rdhnkeiceh HydrcR9 K`cdh fdhnetekeh hydrc ekcget `uke tusuk

U9 K`cdh fdhnetekeh hydrc tdrese mdhet mdhut

W9 K`cdh fdhnetekeh hydrc tdrese aedrel pdrut genceh kcrc

]9 ]ke`e hydrc gdret (]ke`e >) fdhchnket seet gdrndrek

Q9 Hydrc tdrus- fdhdrus

=. RDFDWCK]EEH OC]CK (DK]RJ]TWD)e. Kdeaeeh ufuf sdaehn

g. QQ_Qdkeheh aerel 9 572/32 ffln

Heac 9 521 ke`c pdrfdhct

Rdrhepeseh 9 =2 ke`c pdrfdhct

]ulu 9 => adreiet md`mcus

1. Gdret Geaeh 9 tcaek acukur4. Qchnnc Geaeh 9 tcaek acukur?. Kdpe`e

C 9

Rupc` gdrdeksc tdrleaep meleye, ukureh acefdtdr =ff , csjkjrscfdtrcs keheh aeh kcrc

Qcaek eae `uke, fdfer, tcaek eae pdfgdhnkekeh, tcaek eaeadojrfctes

Qcaek eae mecreh kd`uer aerc lcauhn aeh td`chne NM] 54

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R9

Qcaek eae hydrc tdkeh Qcaek eae gdhij`eh

>. @dldrC9

Qcaek eae tehae-tehae chiury spche` Qcaek eae `uke, tcaek eae adojrfctes, tcaek eae fdfer, aeh tcaek

eae pdfgdhnkekeh

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52. Rd`vcs, Wdktuf aeh Ndhcte`Qcaek eae pdraereleh

55. @dhneh aeh tuhnkecC9

Qcaek eae eae `uke, adojrfctes, fdfer, eteu pdfgdhnkekehR9

Qcaek eae hydrc tdkeh. pescdh aepet fdresekeh sdhsesc sdhtuleh tcaek eae kdtdrgeteseh pdrndrekeh sdhac ]ulu ehnnjte ndrek, tehneh, aeh kekc lehnet

57.RuhnnuhnC9

Qcaek eae `uke, tcaek eae adojrfctes, tcaek eae fdfer, tcaek eaepdfgdhnkekeh, tcaek eae adprdsc tu`ehn

R9

Qcaek eae hydrc tdkehCCC. RDFDWCK]EEH ACENHJ]QCK

T]N EGA9 tcaek fdhdfgus jrneh vcte`

DKN 9 ^H@

LG 9 55,4 %/a`

C_. RDWE^EQEH/RDHNJGEQEH5. Rdreweteh7. Rdhnjgeteh

C_OA W@ 7< QRF

C_OA HeM` 2,3 % 52 QRF

Mdojtexcfd 5222 fn/cv/57 Ief

Kdtjrj`ek =2 Fn/C_/< Ief

Wehctcachd 54 Fn/C_/57 ief

Qrehsefch 422 fn/C_/< ief

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Acenhjse Kdpdreweteh (aerc survdy sdkuhadr) 9

Acenhjse Kdpdreweteh C 9Hydrc Ekut

Oektjr yehn gdrluguhneh9Endh Rdhydgeg ocsck ; `uke tusuk

Wdhmehe Qchaekeh 9

Quiueh9 sdtd`el ac`ekukeh tchaekeh kdpdreweteh sd`efe 5 ief aclerepkeh

k`cdh fdhuhiukkehRdhndhae`ceh hydrc (HJM)yehn acguktckeh

adhneh chacketjr 9

Chacketjr ]ke`e

Dksprdsc peae weiel

kdtdnehneh jtjt

auresc dpcsjad hydrc

fdrchtcl eteu fdhehncs

Nd`csel

=

4

=

4

4

Kdtdrehneh ]ke`e

5. Nehnnueh dkstrdf7. Nehnnueh gdret=. Nehnnueh sdaehn

1. Nehnnueh rchneh4. Qcaek eae nehnnueh

C htdrvdhsc9

Ektcvctes Kdpdreweteh

Feheidfdh Hydrc (HCM)

5. @ekukeh pdhnkeiceh hydrc sdmere kjhordldhsco fd`cputc `jkesc, kerektdrcstck,auresc, ordkudhsc, kue`ctes, oektjr prdscpctesc. (R)

7. Jgsdrvesc csyeret hjhvdrge` kdtcaekhyefeheh (R)=. Eierkeh pdhnnuheeh tdlhck hjhoerfekj`jncs (C)1. Gdrckeh chojrfesc tdhtehn hydrc (C)4. @epjrkeh kdgdrlesc`eh aeh kdtcaekgdrlesc`eh pdhndhae`ceh hydrc (K)?. Kdhae`ckeh oektjr `chnkuhneh yehn fdfpdhnerulc rdspjh pescdh tdrleaep

kdtcaek hyefeheh(C)

Rdfgdrceh ehe`ndtck(HCM)

>. ]dsueckeh ajscs, ordkudhsc sdsuec chackesc aeh dodk sefpchn

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) fdhchnket seet gdrndrek

Q9 Hydrc tdrus- fdhdrus

4. Ief 51.5>Jgsdrvesc csyeret hjhvdrge` kdtcaekhyefeheh

Lesc`;K`cdh tcaek tefpek nd`csel

Dksprdsc weiel fdrchncs

Qefpek pdrc`eku fd`chauhnc aedrel `uke

Keaehn k`cdh fdrchncs kdsekcteh

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Hydrc fescl tdrese tdrusfdhdrus (Q)

J 9 dksprdsc weiel fdrchncs

Nd`csel gdrkurehn

Keaehn pescdh fdrchtcl kdsekcteh

E 9 Fese`el gd`uf tdretesc

R 9 @ehiutkeh chtdrvdhsc 5-3

Acenhjse Kdpdreweteh C C 9

Kdrusekeh chtdnrctes ierchneh pdrcodr

Oektjr yehn gdrluguhneh9`uke tusuk

Wdhmehe Qchaekeh 9

Quiueh 9 sdtd`el ac`ekukeh tchaekeh kdpdreweteh sd`efe 5 ief aclerepkeh k`cdh

fdhuhiukkeh chtdnrctes ierchneh (HJM)yehn acguktckeh adhneh chacketjr 9

Chacketjr ]ke`e

Heac kuet aeh scfdtrcs

sdhsesc ku`ct

]ulu tugul

kdutuleh ku`ct

4

4

4

=

Kdtdrehneh ]ke`e

5. Nehnnueh dkstrdf

7. Nehnnueh gdret=. Nehnnueh sdaehn1. Nehnnueh rchneh4. Qcaek eae nehnnueh

Chtdrvdhsc9

Ektcvctes Kdpdreweteh

Rdreweteh `uke (HCM)

5. Fjhctjr tehae-tehae/ndie`e chodksc (sulu tugul, adhyut iehtuhn, pdfguehneh,pdhefpekeh `uke, sdkrdsc, pdhefpekeh urch, sulu ku`ct, kd`d`eleh)

7. Qdrepkeh pdhmdneleh uhcvdrse`=. Rdhete`ekseheeh pdfgdrceh ehtcgcjtck

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1. @ekukeh pdreweteh `uke adhneh tdlhck stdrc`4. Wuiuk kd acenhjsd kdrusekeh pdrousc ierchnehCfp`dfdhtesc 9

5. Ief 5=.=5 ^cteQdrepkeh pdhmdneleh uhcvdrse`

Lesc`9 Rescdh actdfpetkeh ae`ef ruehn jgsdrvesc/tcaekeh

Ehiurkeh pescdh aeh kd`uerne uhtuk tcaek fdhydhtul uke

7. Ief 5=.=< wcte@ekukeh pdreweteh `uke adhneh tdlhck stdrc`

Lesc`9 `uke acgdrsclkeh adhneh tdlhck stdrc` fdhnnuhekeh Hem` 2,3%,

tutup adhneh lees.

=. Ief 51.54 wcteRdhete`ekseheeh pdfgdrceh ehtcgcjtck

Lesc` 9pdfgdrceh mdojtexcfd 5222 fn/cv

1. Ief 51.72 wcteFjhctjr tehae-tehae/ndie`e chodksc (sulu tugul, pdhefpekeh `uke, sdkrdsc,

pdhefpekeh urch, sulu ku`ct, kd`d`eleh)

Lesc`9 ]ulu => adreiet md`mcus, R9 K`cdh fdhnetekeh hydrc ekcget `uke tusuk

fescl tdrese, tdrpesehn vdrgeha peae `uke, sulu ku`ct lehnet, ekre` dkstrdfctes

achnch.

Dve`uesc 9

Qehnne` 53 Iuhc 7251 ief 51.73

] 9 -

J 9 ]ulu => adreiet md`mcus,

tdrpesehn vdrgeha peae `uke,

sulu ku`ct lehnet

ekre` dkstrdfctes achnch.

E 9 Fese`el gd`uf tdretesc

R 9 @ehiutkeh chtdrvdhsc 5-1

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Acenhjse Kdpdreweteh C C C 9

Kdkurehneh vj`ufd mecreh

Oektjr yehn gdrluguhneh9kdlc`ehneh aerel yehn eghjrfe`

Wdhmehe Qchaekeh 9

Quiueh9

sdtd`el ac`ekukeh tchaekeh kdpdreweteh sd`efe 5 ief aclerepkeh k`cdh ekeh

fdhuhiukkeh kdsdcfgehneh d`dktrj`ct esef aeh gese (HJM) adhneh chacketjr9

Chacketjr ]ke`e

Ordkudhsc heac aeh crefe (Hjrfe`

?2-522 ke`c pdrfdhct)

Ordkudhsc Hepes (Hjrfe` 57-72 ke`c

pdrfdhct)

Jrcdhtesc kjnhctco

4

4

4

Kdtdrehneh ]ke`e5.Nehnnueh dkstrdf

7. Nehnnueh Gdret

=. Nehnnueh sdaehn1. Nehnnueh rchneh4. Qcaek eae nehnnueh

C htdrvdhsc9

Ektcvctes kdpdreweteh9

Feheidfdh Mecreh (HCM)

5.

Rehteu stetus lcaresc (kd`dfgepeh fdfgreh fukjse, kdeadkueteh heac, aehtdkeheh aerel jrtjstetck) ( R)

7. Rdrtelehkeh kdekureteh meteteh chtekd aeh jutput (R)=. Ehiurkeh pescdh uhtuk fdhnchojrfesckeh epegc`e leus(C)1. Etur kdtdrsdaceeh prjauk aerel uhtuk trehsousc (K)4. Gdrckeh tldrepc Chtre vdhe (K)?. Resehn ketdtdr urchd (K)>. Rehteu lesc` @egjretjrcuh aerel aeh sdruf d`dktrj`ct (K)Cfp`dfdhtesc 9=. Ief 5=.=4 ^cte

fdfgdrckeh tldrepc Chtre vdhe

Lesc`9 tdrpesehn mecreh HEM@ 2,3% 52 tdtds pdrfdhct aeh mecreh W@ 7< tdtds

pdrfdhct fdhnnuhekeh tlrdd wey ac tehneh keheh.

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1. Ief 5=.=? ^cteFdfesehn ketdtdr urchd

Lesc`9 tdrpesehn ketdtdr urchd, jutput urchd9 werhe kuhchn, iuf`el 522 m,

tcaek eae ldfeturce

4. Ief 51.52 ^cteFdhnetur kdtdrsdaceeh prjauk aerel uhtuk trehsousc

Lesc`9 tdrsdace aerel J rldsus pjsctco = gen

?. Ief 51.72 ^cteFdfehteu stetus lcaresc (kd`dfgepeh fdfgreh fukjse, kdeadkueteh heac,

aeh tdkeheh aerel jrtjstetck)

Lesc`9Fdfgreh fukjse `dfgeg, Heac kuet ordkudhsc heac 521 ke`c pdrfdhct,

tdkeheh aerel 572/32 ffln

Dve`uesc 9

Qehnne` 53 Iuhc 7251 ief 51.=2

] 9 -

J 9 Heac 521 ke`c pdrfdhct

Kue`ctes heac kuet

Qdkeheh aerel 572/32 ffln

Kdseaereh mjfpjsfdhtcs, NM] 54

E 9 Fese`el gd`uf tdretesc

R 9 @ehiutkeh chtdrvdhsc 5-?

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Acsmlernd R`ehhchn

(Rdrdhmeheeh Ru`ehn/Qchaek @ehiut Wewet Chep)

Acenhjse Kdpdreweteh Qchaekeh kdpdreweteh

kdtcaekdodktcoeh pj`e hepes

Qehnne` 53 Iuhc 7251 ief 5=.=2^cte

] 9 K`cdh fdhnetekeh sdsek gdrkurehnJ 9 Ordkudhsc Hepes 7< ke c pdrfdhct

J7 tdrpesehn 1 @RF gchese`

E 9 Fese`el Gd`uf tdretescR 9 @ehiutkeh chtdrvdhsc

Wcsckj ]yjk

] 9 -J 9 Heac 521 ke`c pdrfdhct

Kue`ctes heac kuet

Qdkeheh aerel 572/32 fflnKdseaereh mjfpjsfdhtcs, NM] 54

E 9 Fese`el gd uf tdretescR 9 @ehiutkeh chtdrvdhsc 5-?

Kdkurehneh vj`ufd mecreh

Qehnne` 53 Iuhc 7251 ief 51.=2] 9 -

J 9 Heac 521 ke`c pdrfdhctKue`ctes heac kuetQdkeheh aerel 572/32 ffln

Kdseaereh mjfpjsfdhtcs, NM] 54E 9 Fese`el gd`uf tdretescR 9 @ehiutkeh chtdrvdhsc 5-?

Hydrc ekut

] 9 K`cdh fdhnetekeh hydrc fescl tdrese (R)Kue`ctes sdpdrtc mdhet mdhut (U)Hydrc aedrel pdrut kcrc(W)]ke`e hydrc gdret (]ke`e >) (])

Hydrc fescl tdrese tdrusfdhdrus (Q)J 9 dksprdsc weiel fdrchncs

Nd`csel gdrkurehnKeaehn pescdh fdrchtcl kdsekcteh

E 9 Fese`el gd`uf tdretescR 9 @ehiutkeh chtdrvdhsc 5-3

kdrusekeh chtdnrctes ierchneh

Qehnne` 53 Iuhc 7251 ief 51.73] 9 -

J 9 ]ulu => adreiet md`mcus,tdrpesehn vdrgeha peae `uke,

sulu ku`ct lehnetekre` dkstrdfctes achnch.

E 9 Fese`el gd`uf tdretescR 9 @ehiutkeh chtdrvdhsc 5-1

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4=

Hefe pescdh Qh.E, @ /R, fesuk rufel sekct peae tehnne` 53/2?/7251 ief 5=.=2adhneh

acenhjse fdacs _u`hus Ruhmtuf Wdncj @ufger Egajfdh ]ch cstre Ehtdrcjrtd`el acgdrckeh

tchaekeh kdpdreweteh ac etes. Thtuk ctu pdr`u pdreweteh `ehiuteh ac Wuehn JK W]TC Oecse`

fu`ec tn` 53/2?/7251

Qdrepc jget yehn acgdrckeh 9

Ief 51.52 kdtjrj`ek =2fn/cv

Ief 51.5= rehc tcachd 54 fn/cv

Ief 51.54 mdojtexcf 5222fn/cv

Ehiureh 9 `ehi utkeh rdhmehe kdpdreweteh

Wuiuk kd acenhjse rcsckj cho dksc gc`e gc` e pdr` u

Fekesser, 53/2?/7251

Hurocae, ].Kdp