LP RASA AMAN & NYAMAN

(1)

LAPORAN PENDAHULUAN ASUHAN KEPERAWATAN PADA

PASIEN DENGAN GANGGUAN PEMENUHAN RASA

NYAMAN

Oleh :

NI LUH NILAM SHANTI CA

NI LUH NILAM SHANTI CAHY

HYANI

ANI

(P07120215033)

DIV-KEPEA!ATAN

KEMENTE

KEMENTEIAN

IAN KESEHA

KESEHAT

TAN 

AN II

POLITEKNIK KESEHATAN DENPASA

TAHUN A"AAN 2015#201$

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LAPORAN PENDAHULUAN KEBUTUHAN

RASA NYAMAN

A. Pengertian

Ke%&''%'% e*'+', '. /e'''% .el'h .ee%h, Ke*.h'% D'' M'%,' /e*.h'% ,%, el,., /e*.h'% '/'% /e.e%.''% ('. /e''% &'%+ e%,%+/'./'% e%',l'% eh',-h',) /ele+''% (/e*.h'% .ee%h,) '% .'%e%e% (/e'''% .e%.'%+ e'. &'%+ ele*,h, ''l'h#%&e,)4 (Kl6'*' 12 'l' P..e 8 Pe& 9 le 2)

;'%++'% /e%&''%'% ''l'h /e'''% /e.,/' ,%,, e%+'l', e%', &'%+ .,'/ e%&e%'%+/'% 'l' *ee% .eh'' '. '%+'%+'% &'%+ *e*'h'&' (C'e%,. L,%' "'l 2000)

Me%. Cl'%e& '% M6 V,6' (12) N&e, e'/'% .'%' e,%+'.'% *'h<' .e=', /e'/'% =',%+'% &'%+ e%=', e.,*'%+'% e'<'. ''. e%+/'=,4 N&e, e'/'% '. /%,, &'%+ le*,h ', e/e' e%', .%++'l &'%+ ,e*'*/'% leh .,l .e.e%. %&e, *e,>'. *=e/.,> '% ,%,,'l .,l %&e, ''. *e' .,l &'%+ *e,>'. >,,/ '.' e%.'l e'%+/'% /e'/'% ''. .e=', '' =',%+'% '/.'l '.' >%+, e+ ee'%+ ,%,, (M'h% 19)

'4 N&e, A/.

Me%. I%.e%'.,%'l A6,'.,% > .he S.& > P',% ''l'h e%+'l''% e%, '% e,%'l .,'/ e%&e%'%+/'% &'%+ %6l '/,*'. /e'/'% =',%+'% &'%+ '/.'l '.' .e%,'l#,+'*'/'% 'l' h'l /e'/'% ee,/,'% ' '<,.'% &'%+ .,*'#l'*'. ', ,%.e%,.' ,%+'% h,%++' *e'. e%+'% '/h, &'%+ ''. ,'%.,,', '% *el'%+%+ ? $ *l'%

*4 N&e, K%,/

Me%. I%.e%'.,%'l A6,'.,% > .he S.& > P',% ''l'h Pe%+'l''% e%, '% e,%'l .,'/ e%&e%'%+/'% &'%+ %6l '/,*'. /e'/'% =',%+'% &'%+ '6.'l#.e%,'l#,+'*'/'% 'l' h'l /e'/'% ee,/,'% ' '<,.'% &'%+ .,*'-.,*'#l'*'. ', ,%.e%,.' ,%+'% h,%++' *e'. .e=', e6'' /%.'% '.' *el'%+ .'%' '/h, &'%+ ''. ,'%.,,', '% *el'%+%+ $ *l'%4

A. Tanda dan Gejala

e% e,l'/ .eh'' %&e, ''. e%6'/:

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24 E/e/, <'='h (e,%+, e%+e=,./'% 'h, e%++,+,. *,*, e%++ele.//'% +,+,)

34 ;e'/'% .*h (+el,'h ,*,l,', /e.e+'%+'% .. e%,%+/'.'% +e'/'% =', '% .'%+'%)

94 I%.e'/, ,'l (e%+h,%', e6'/''% >6 h'%&' /e'' '/.,>,.' e%+h,l'%+/'% %&e,)

54 I%,, &'%+ e%+'l', %&e, ''. *ee'/, '%+'. *e*e' .eh'' %&e, &'%+ *el'%+%+ el'' *e*e'' e%,. h,%++' e%=', /%,4

e% ,/l+, ''l'h *e/',.'% e%+'% e'h''% /l,e% .eh'' %&e, '.' '., %&e, *'+, /l,e%

e% >,,l+, .eh'' %&e,:

') S.,l', S,'.,/ (%&e, ,%+'% e'. e>,6,'l) 14 D,l'.', 'l'% *%6h,'l '% e%,%+/'.'% e,', '.e 24 Pe%,%+/'.'% he'. '.e

34 Pe%,%+/'.'% /e/'.'% .. 94 V'/%.,/, e,>e 54 D,l'.', ,l $4 Pe%%'% .,l,.' ;I *) S.,l P'','.,/ (N&e, *e'. '% 'l') 14 M/' 6'. 24 O.. e%+e' 34 Pe%%'% H '% @P 94 N'>' 6e'. '% ,e+l' 54 N'e' $4 Kelel'h'% '% /ele.,h'% B. P!n Ma"ala! .e'. Mekanik 1. Kerusakan Intergumen 2. Trauma jaringan

Smulus Nyeri Kram abdomen, diare, muntah

Tumor/kanker

Sasme otot Termal

Imuls Nyeri

Medula SinalisTimbul Nyeri Skala Nyeri !erubahan Na"su makan Keterbatasan #erak $esistansi Kedakseimbangan Nutrisi Krisis Situasi #angguan Mobilisasi %in in !anas

& ' Tidak Nyeri 1 2 Nyeri ringan ( ) * Nyeri sedang +  - Nyeri berat  1 ' Nyeri hebat

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#. Pe$eri%"aan Diagn"i"

14 ,<'&'. Pe%&'/,. '% Kelh'%

P'' ,<'&'. e%&'/,. e%.,%+ ,.e%./'% 'hl /elh'% .'' ,'l%&' %&e, '' *''l /ele'h'% '% l/', /elh'%4 D,.'%&'/'% l' '/.,,.' '% ,, /e'l' &'%+ e%,%+/'./'% '% e%+'%+, /elh'% '% ''%&' ,<'&'. 6,e'4

24 Pee,/''% >,,/

Pee,/''% >,,/ el,.,:

'4 O*e', eh'.,/'% ,/' .*h ',e% ''. e%'%&'/'% ,<'&'. e%&'/,.4 *4 P'l', '' 'l', ''*,l' ,''./'% /e/'/'% '% %&e, '' ,, ..

'% ',/ ''> &'%+ .e/e%' ''. l' ,e.', h,e.% '% 'e '' ,, .. &'%+ %&e,

Konsus %orsalis

Thalamus

Korteks Serebri

0kibat Nyeri

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64 Pee,/''% US; %./ '.' e%%='%+ ''*,l' '' %&e, .e/'% , '*e% 4 %.+e% %./ e%+e.'h, .l'%+ '.' +'% &'%+ '*%'l

e4 Pee,/''% l'* e%'+', '.' e%%='%+

>4 C>-S6'% (6,e' /e'l') %./ e%+e.'h, ''%&' e*lh ''h &'%+ e6'h , .'/4

D. Penatala%"anaan Medi" 14 N% ''/l+,

'4 D,.'/, e%+'l,h/'% eh'.,'% /l,e% .eh'' e'. &'%+ e%',/ ,'l%&' e%%.% TV (P,h'=1$)

*4 S.,l', /l,. ee., /e ,%+,% C%.e,.e% (le.e h'%+'.) 6%.'l'.e'l (e'+e /l,. '' 'e' &'%+ *el'<'%'% e%+'% %&e,)

24 ''/l+, (A%'l+e,/ N% N'/.,/) '4 N&e, ,%+'% I (''/l+, I) A,,% 325-$50 + 9 =' e/'l, Ae.',%>e% 325-$50 + 9-$ =' e/'l,4 *4 N&e, ,%+'% (''/l+, II) I*>e% 200 + 9-$ =' e/'l, Ke.>e% 125 + 9-$ =' e/'l, S, '<'l'% 990 + el'%=.%&' 220 + B-12 =' e/'l, 64 N&e, e'%+ (''/l+, III)

Ae.',%>e% 9-$ =' e/'l, I*>e% 9-$ =' e/'l,

S, %'/e% B-12 =' e/'l, 4 N&e, e'%+ (''/l+, IV)

T''l 50-100 + 9-$ =' e/'l, e4 N&e, *e'. (''/l+, VII)

M,% *,l' .e', %% %'/.,/ .,'/ e>e/.,> '' ,<'&'. .e', %'/.,/ '' %&e,

A%'l+e,/ %'/.,/ .e,, ', *e*'+', e,'.e , ee., >,% '% /e,%4

E. Peng%ajian Ke&era'atan

D'.' e'<'.'% &'%+ ,/'=, '% e., ,''. ''l'h:

14 Al''% MS &',. /elh'% .'' ',e% ''. MS '% ''. ,/'=,4 P',e% e%+elh %&e, ,l'%=./'% e%+'% ,<'&'. /eeh'.'% e/''%+ 'hl '% /el'+'4

24 Ke*.h'% '' N&''% (N&e,)

D'.' ,''./'% e%+'% '%'%e' %./ e%+/'=, /''/.e,.,/ %&e, &'%+ ,%/'/'% leh ',e% el'l, e%e/'.'% PT4 Pee,/''% >,,/ ,l'//'% %./ e%''./'% ee,/''% >,,/ ,l'//'% %./ e%''./'% e*'h'% /l,%, &'%+ ,'/,*'./'% %&e,4 D'.' &'%+ ,''. e%e,' e% /l,e% *e,/. e%=el''% PS:

'4 P (P/'.,e): '/. &'%+ ee%+'h, +'<'. '.' ,%+'%%&' %&e, *4  ('l,.&) : See., ''/'h '' %&e, .'=' .l .e'&'.

64  (e+,%) : D'e'h e='l'% %&e,

(6)

e4 T (T,e) : L'' '.' <'/. '% >e/e%, %&e,4 @e,/. /'l' %&e, %./ e%+e.'h, ,%.e%,.' %&e,4

Ne,:

0 T,'/ N&e,1 2 3 9 5 $ 7 B  10

N&e, ,%+'% N&e, Se'%+ N&e, @e'. N&e, T'/ Te.'h'%/'%

"', h'l &'%+ el ,/'=, :

1. L/', %./ e%e./'% ,%.' /l,e% e%%/'% 'e' %&e,

24 I%.e%,.' '% /'l,.' %&e, el e%6'.'. /'.'-/'.' /l,e% 'l' e%++'*'/'% %&e,4

34 Pl' e'<'. e%+/'=, /''% %&e, ,l', *e''l'' *el'%+%+ ''/'h *el'%+ /''% .e'/h, %6l4

94 '/. Pe,,.', .e/''%+ '/.,>,.' .e.e%. ''. e,6 %6l%&e, >'/. l,%+/%+'% &'%+ '%+'. ,%+,% '.' '%' .e >,,/ '% e,%'l '.' =+' e,6 %6l%&' %&e,

(. Diagn"a Ke&era'atan

Te''. *e*e'' ,'+%, &'%+ *eh*%+'% e%+'% '+e% 6ee' ( *,l+,/,,'

14 N&e, '/. *eh*%+'% e%+'% '+e% .'' (  *,l+, /,,' >,,/ ,/l+,) /e'/'% =',%+'%4

24 N&e, /%,/ *eh*%+'% e%+'% /e.,'/''% >,,/ /%, /e.,'/''% ,/,'l /%,4 G. $enana Keera3atan N D D,'+%' Kee'<'.'% T='% I%.ee%, ',%'l 1 N&e, '/. *eh*%+'% e%+'% '+e% .'' (*,l+,/,,'>,,//l+, ) /e'/'% =',%+'% Se.el'h ,l'//'% .,%'/'% /ee'<'.'% el'' 329 =' ,h''/'% %&e,*e/'%+ e%+'% 6,.e,' h',l : 14 M' e%+%.l %&e, 24 M' e%+e%'l, >'/.  L'//'% e%+/'=,'% %&e, el,., l/', /''/.e,.,/ ', >e/e%, /'l,.' ,%.e%,.' '% e%&e*''%  /%.l >'/. l,%+/%+'% &'%+ ''. ee%+'h, e% /e.,'/%&''% U%./ e%e%./'% .,%'/'% /ee'<'.'% &'%+ ,*e,/'% Me%%/'% /e.,'/%&''%'%

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