LP & ASKEP SEPSIS (WULAN)

LAPORAN PENDAHULUAN DAN ASUHAN KEPERAWATAN PADA KASUS SEPSIS

DI RSUD dr. ISKAK TULUNGAGUNG

2013/2014

DI SUSUSN OLEH;

TRI WULAN SARI

02.12.038

STIKes HUTAMA ABDI HUSADA TULUNGAGUNG

2013/2014

JURNAL

http://search.proquest.com/docview/759553860/D53C69D99E2A4FE2PQ/4?accountid=62692#center

Parenteral nutrition line sepsis: the difficulty in diagnosis

McWhirter, Derek. The Proceedings of the Nutrition Society69.4 (Nov 2010): 508-10.

Turn on hit highlighting for speaking browsers

Hide highlighting

Parenteral nutrition (PN) line sepsis is a common and yet poorly managed complication in hospitalised patients receiving PN. Making a clinical diagnosis is difficult as the clinical picture can be very non-specific and definitions of what constitutes line infection can vary. Once there is clinical suspicion, proving it with microbiological techniques is not an exact science. Traditional techniques have required the removal of the PN line to allow microbiologists to perform analysis of it for infection. This has obvious drawbacks as it is often not easy to replace the line in these patients and the line is often later proven not to be the source of the sepsis. Although the gold-standard technique still requires removal of the line, there has been development in the field of diagnosis line infection while conserving the line. These include intra-luminal brushings of the line, differential blood cultures and simple Dswabs of the line hub. These techniques are not as sensitive but reduce the problems caused by removing and re-inserting the line in these patients. The definition of PN line sepsis varies between institutions. Rates can be expressed as a true number of cases, or can be expressed correctly as a number of cases per 1000 line days to standardise rates between units of differing sizes. Rates can also be altered if the diagnostic criteria are too strict or too lax. Accurate diagnosis of PN line sepsis remains difficult in modern medical practice. [PUBLICATION ABSTRACT]

 (ProQuest: ... denotes non-US-ASCII text omitted.)

Symposium 4: Whose fault was it anyway? Competencies in training

13-14 October 2009

The Annual Meeting of the Nutrition Society and BAPEN

Cardiff International Arena, Cardiff

Abbreviation:

PN

parenteral nutrition

Parenteral nutrition (PN) line sepsis is a common complication in hospitalised patients receiving PN. Studies in Europe have shown that rates of bloodstream infections related to indwelling venous lines can vary from 22·5% to a staggering 66% of cases^(1,2). Hospitalised patients receiving PN are often critically ill and making a confident, expedient diagnosis of PN line sepsis can be difficult. Early clinical suspicion, investigation, diagnosis and treatment are necessary to ensure that these unwell patients do not deteriorate quickly. Appropriate management of the PN line is necessary, along with appropriate microbiological input to help confirm the diagnosis.

Aetiology

A PN line can become infected in a number of ways: (1) poor aseptic technique when inserting the line; (2) migration of organisms along the line; (3) poor aseptic technique and line care when using the line; (4) contaminated infusions; (5) haematogenous spread from distant foci of infection ⁽³⁾.

Clinical diagnosis

Clinical suspicion must be raised when a patient on PN becomes unwell and/or pyrexial. Sepsis related to the PN line does not always cause a rise in serum inflammatory markers of infection such as white cell count or C-reactive protein, meaning that more emphasis is placed on microbiological techniques to confirm the diagnosis. Often the PN line suspected of causing sepsis is removed and sent to microbiology. Unfortunately only about 20% of lines removed are found to have been infected, meaning that there was no need to remove the line and the patient is likely to require insertion of another ^(4-6). This has led to the development of line-conserving techniques to diagnose infection.

Non-line-conserving techniques

The most common techniques used to confirm line infection following removal of the line are a qualitative procedure, Maki's semi-quantitative procedure, quantitative endoluminal cultures after flushing, and sonication.

The qualitative procedure involves culturing the tip of the PN line for organisms. This is the simplest technique but is not used often due to a relative lack of specificity at around 75%⁽⁷⁾. The accuracy of this technique is affected by the fact that a line may be colonised by organisms without causing sepsis in the patient. Clinical correlation must be used when interpreting results using this technique.

Maki's semi-quantitative procedure was first described in 1977. It is still used as the international reference. It involves rolling the line tip on an agar plate and culturing it. An arbitrary number of colony forming units set at >15 is used to indicate a positive culture ⁽⁸⁾. A high specificity of >75% has been reported with this technique.

Quantitative cultures of fluid repeatedly flushed through the PN line lumen have also been used to help with diagnosing infection. This has the advantage of including organisms within the line lumen rather than just those on the outside of the tip⁽⁹⁾. Again an arbitrary number of colony forming units of organisms is set as a positive result. This technique is not used in everyday practice because of the large workload it would generate.

Sonication is a newer method that was developed in the 1990s. This technique involves bathing the line in the culture broth and subjecting it to high-frequency ultrasound. The broth is then diluted and cultured using the normal technique for qualitative procedure. Using ultrasound it is able to improve the diagnostic specificity, but requires extra equipment and time and as such is not practical for everyday use ⁽¹⁰⁾.

Line-conserving techniques

It would be preferable to confirm line infection before removing the line, and therefore a number of techniques have been developed which leave the line in place until infection is confirmed. Usually if there is serious suspicion of line infection, these techniques are used and PN is stopped until the result is obtained. The most common techniques are intraluminal brushing, semi-quantitative swabs from the external line and differential quantitative blood cultures.

Intraluminal brushing was first tried in 1989. This technique involves using a specially designed wire brush and passing it down the line suspected of being infected. The theory is that the organisms on the fibrin sheath on the inside of the line become caught up on the bristles of the brush which is then removed and sent for culture ⁽¹¹⁾. The results were initially good, but concerns about the risks of the technique led to it being discarded as a popular method of diagnosing infection⁽¹²⁾. Side effects included cardiac arrhythmias from inserting the wire brush too far or the risk of endocarditis caused by dislodging infection from the line and sending emboli to the valves.

Taking simple microbiology swabs from the external portion of the line has proved to be effective, although this is not able to diagnose all infections⁽¹³⁾. This involves using simple culture swabs to swab the area where the line hub enters the skin. It is not exact as not all line infections are found at this part of the line and all infections under the skin or on the line tip are missed by this technique.

Differential blood cultures involve drawing blood for culture both from the PN line suspected of sepsis and from a distal, peripheral site and comparing the two. If the concentration of organisms in the two cultures is the same, then the line is unlikely to be the source of the infection. If the concentration is higher in the line cultures, then it is likely to be infected. A ratio of between 5:1 and 10:1 is accepted as positive. It is not always possible to perform this technique as the PN lines are often made of a very soft material that collapses when suction is applied, meaning that drawing back blood from the line is not always possible ^(14,15). The line tip may also become covered by a fibrin sheath that prevents aspiration of blood.

Defining parenteral nutrition line sepsis

It is clear from the literature that no clear definition of PN line-related sepsis exists.

Depending on which definition is used, a patient may or may not be formally diagnosed as having PN line-related sepsis. The definitions used in clinical practice and in the published literature exist as a spectrum. At one end the simplest definition is a clinical suspicion of PN line-related sepsis where pyrexia is associated with the use of PN and this subsides on stopping the PN and no other source is found. This can obviously include many false-positive cases and lead to an over-diagnosis of PN line sepsis. At the other end of the spectrum, a diagnosis may only be made once positive blood cultures and a positive line tip are found in the presence of clinical suspicion. This is not always possible to achieve, leading to many cases being unfairly discounted leading to an under-representation of the true incidence. Different units may apply these different diagnostic criteria to diagnose line sepsis. It is therefore very difficult to accurately estimate what the actual incidence of sepsis is and how each unit is performing compared to the national average. It is accepted in the literature that rates should be corrected as number of events per 1000 line days to standardise each unit's rate of sepsis. If national audit is to be carried out in this area, a nationally accepted standardised definition must be agreed on. Table 1 shows how the incidence of PN line sepsis can be altered, depending on what definition is used in a large unit in Glasgow ⁽¹⁶⁾. The numbers are shown as the actual numbers of cases with the number of cases per 1000 line days shown in brackets.

Table 1.

Rates of parenteral nutrition (PN) line-related sepsis varying by definition from Glasgow Royal Infirmary

Conclusion

Improvement in the education of those involved in the management of these patients combined with good quality input from microbiologists is vital to improving the care of these patients. This could include increased teaching of doctors at the medical school or foundation training stage into the issues surrounding line infection and line care. Improved awareness among nursing staff about the importance of good line care is also essential.

Acknowledgements

There are no conflicts of interest. No funding was received for this article.

References

References

1. 1.O Ronveaux, B Jans, C Suetens (1998) Parenteral nutrition line sepsis: the difficulty in diagnosis. Eur J Clin Microbiol Infect Dis 17, 695-700.

2. 2.J Raymond & Y Aujard (2000) Parenteral nutrition line sepsis: the difficulty in diagnosis. Infect Control Hosp Epidemiol 21, 260-263.

3. 3.E Bouza, A Burillo & P Munoz (2002) Parenteral nutrition line sepsis: the difficulty in diagnosis. Clin Microbiol Infect 8, 265-274.

4. 4.J Ryan, R Abel, W Abbott (1974) Parenteral nutrition line sepsis: the difficulty in diagnosis. N Engl J Med 290, 757-761.

5. 5.R Blackett, A Bakran, J Bradley (1978) Parenteral nutrition line sepsis: the difficulty in diagnosis. Br J Surg 65, 393-395.

6. 6.J Linares, MA Dominguez & R Martin (1997) Parenteral nutrition line sepsis: the difficulty in diagnosis. Rev Clin Esp 197, Suppl. 2, 19-26.

7. 7.L Michel, H Marsh, J McMichan (1981) Parenteral nutrition line sepsis: the difficulty in diagnosis. JAMA 245, 1032-1036.

8. 8.DG Maki, CE Weise & HW Sarafin (1977) Parenteral nutrition line sepsis: the difficulty in diagnosis. N Engl J Med 296, 1305-1309.

9. 9.D Cleri, M Corrado & S Seligman (1980) Parenteral nutrition line sepsis: the difficulty in diagnosis. J Infect Dis 141, 781-786.

10. 10.R Sherertz, I Raad, A Belani (1990) Parenteral nutrition line sepsis: the difficulty in diagnosis. J Clin Microbiol 28, 76-82.

. AuthorAffiliation

Mersey Deanery School of Surgery, Warrington General Hospital, Lovely Lane, Warrington WA5 1QG, UK

LAPORAN PENDAHULUAN

PADA KASUS SEPSIS DI IGD RSUD dr. ISKAK TULUNGAGUNG

A.    PENGERTIAN

Sepsis adalah Infeksi berat dengan gejala sistemik dan terdapat baketri dalam darah  (Surasmi, 2003.hal 92 )

Sepsis adalah Sindrom yang dikatarakteristikan oleh tanda –tanda klinis dan gejala – gejala infeksi yang parah yang dapat berkembang kearah septismia dan shock ( Dongoes Marikin E 2002.821)

B.     ETIOLOGI

Mikroorganisme penyebab yang paling umum dari syok sepsis adalah bakteri gram-negatif. Namun demikian, agen infeksius lain seperti gram positif dan virus juga dapat menyebabkan syok sepsis. Ketika mikroorganisme menyerang jaringan tubuh, pasien akan menunjukkan suatu respon imun. Respon imun ini membangkitkan aktivitas berbagai mediator kimiawi yang mempunyai berbagai efek yang mengarah pada syok. Peningkatan permeabilitas kapiler, yang mengarah pada pembesaran cairan dari kapiler dan fasodilatasi adalah dua efek tersebut.

C.    PATOFISIOLOGI

Infasi Kuman

↓

Pelepasan Indotoksin

↓

Disfungsi dan kerusakan endotel dan disfungsi organ multipel

↓

SEPSIS

 

↓                                              ↓                                              ↓                                              ↓

Perubahan  fungsi                   Perubahan ambilan      Terhambatnya          terganggunya sistem

Miokardium                            dan penyerapan O2     fungsi mitokondria                  pencernaan

↓                                              ↓                                              ↓                                              ↓

Kontraksi                                Suplai O2 terganggu   kerja sel menurun                   reflek ingin

Jantung menurun                     ↓                                              ↓                                     mutah

↓                                              sesak                            penurunan sistem imun                       ↓

Curah jantung                         ↓                                              ↓                                  anoreksia

Menurun                                  gg. Pmnhan O2           Resti infeksi    gg. Pemenuhan kebutuhan

↓                                                                                                                                  nutrisi

Reduksi darah

Terganggu

↓

gg.perfusi jaringan

D.    PEMERIKSAAN PENUNJANG

Pengobatan terbaru syok sepsis mencakup mengidentifikasi dan mengeliminasi penyebab infeksi yaitu dengan cara pemeriksaan- pemeriksaan yang antara lain:

1.      Kultur (luka, sputum, urin, darah) yaitu untuk mengidentifikasi organisme penyebab sepsis. Sensitifitas menentukan pilihan obat yang paling efektif.

2.      SDP : Ht Mungkin meningkat pada status hipovolemik karena hemokonsentrasi. Leucopenia (penurunan SDB) terjadi sebalumnya, diikuti oleh pengulangan leukositosis (1500-30000) d4engan peningkatan pita (berpindah kekiri) yang mengindikasikan produksi SDP tak matur dalam jumlah besar.

3.      Elektrolit serum: Berbagai ketidakseimbangan mungkin terjadi dan menyebabkan asidosis, perpindahan cairan dan perubahan fungsi ginjal.

4.      Trombosit : penurunan kadar dapat terjadi karena agegrasi trombosit

5.      PT/PTT : mungkin memanjang mengindikasikan koagulopati yang diasosiasikan dengan hati/ sirkulasi toksin/ status syok.

6.      Laktat serum : Meningkat dalam asidosis metabolik, disfungsi hati, syok

7.      Glukosa Serum : hiperglikenmio yang terjadi menunjukkan glikoneogenesis dan glikonolisis di dalam hati sebagai respon dari puasa/ perubahan seluler dalam metabolisme

8.      BUN/Kreatinin : peningkatan kadar diasosiasikan dengan dehidrasi, ketidakseimbangan atau kegagalan ginjal, dan disfungsi atau kegagalan hati.

9.      GDA : Alkalosis respiratosi dan hipoksemia dapat terjadi sebelumnya. Dalam tahap lanjut hipoksemia, asidosis respiratorik dan asidosis metabolik terjadi karena kegagalan mekanisme kompensasi

10.  EKG : dapat menunjukkan segmen ST dan gelombang T dan distritmia menyerupai infark miokard

E.     INTERVENSI

DP:

1.      Resiko infeksi b.d penurunan sistem imun, kegagalan untuk mengatasi infeksi, infeksi nosokomial.

Tujuan : Menunjukkan penyembuhan seiring perjalanan waktu, bebas dari sekresi purulen/ drainase atau eritema dan afebris

Tindakan:

1. Cuci tangan sebelum dan sesudah melakukan aktivitas

R : Mengurangi kontaminasi

2. Dorong penggantian posisi sering, nafas daam/ batuk

R : Bersihan paru yang baik mencegh pneumonia

3. Gunakan sarung tangan pada waktu merawat luka

R : Mencegah penyebaran infeksi/ ontaminasi

4. Gunakan teknik steril pada setiap tindakan: ganti balut, Suction, kateter urinarius dll.

R : Mencegah asuknya bakteri, mengurangi infeksi nosokomial

5. Ambil specimen urin, darah, sputum, luka

R : Identifiksi terhadap portal entri dan organisme penyebab septisemia dalah penting bagi efektivitas pengobatan

6. Berikan obat anti infekasi sesuai advis dokter

R :  Memberikan imunitas sementra untuk infeksi umum atau penyakit khusus misalnya: rabies

DP

2.      Hipertermia b.d peningkatan tingkat metabolisme penyakit, dehidrasi, efek langsung dari endotoksin pada hipotalamus, perubahan pada regulasi temperature

Tujuan: Mnunjukkan suhu dalam batas normal, bebas dari kedinginan

               Tidak mengalami komplikasi yang berhubungan

Tindakan:

1. Pantau suhu pasien

R : suhu lebih dari normal menunjukkan infeksius akut

2. Berikan kompres hangat

R : dapat membantu mengurangi demam

3. Berikan antiseptik

R : Untuk mengurangi demam

4. Berikan selimut pendingin

R : Untuk mengurangi demam pada waktu terjadi gangguan pada otak

DP

3.      Resiko tinggi terhadap perfusi jaringan b.d hipovolemi rewlatif/ actual, reduksi aliran darah pada vena atau arteri, vasoonmstriksi selektif

Tujuan : Menunjukkan perfusi adekuat yang dibuktikan dengan tanda-tanda vital sign stabil, nadi perifer jelas, kulit hangat dan kering, tingkat kesadarn umum, haluaran urinarius individu yanfsesuai dan bising usus aktif.

Tindakan:

1. Pertahankan tirah baring: bantu perawatan pasien

R : Menurunkan

2. Pantau TTV pasien

R : Memantau TTV pasien

3. Pantau frekuensi dan irama jantung

R : bila terjadi takikardi mengacu pada stimulasi sekunder sistem saraf simpatis  untuk menentukan respond an untuk menggantikan kerusdakan pada hipovolemia relative Dan hipertensi

4. Perhatikan kualitas/ kekuatan dari denyut jantung

R : pada awala nadi cepat karena peningkatan curah jantung

5. Catat haluaran urinarius setiap jam dan berat jenisnya

R : penurunan haluaran urin dengan peningkatan berat jenis akan mengindikasikan penuruynan perfungsi ginjal yang dihubungkan dengan perpindahan cairan dan vasokonstriksi relatif

6. Auskultasi bising usus

R : penurunan aliran darah pada ,esenterium menurunkan peristaltik

7. Berikan cairan parenteral

R : Untuk memepertahankan perfusi jaringan

8. Berikan suplemen O₂
9. R : Memaksimalkan O₂ yang tersedia untuk masukan seluler

DP

4.      Resiko tinggi terhadap kekurangan volume cairan b.d peningkatan vasodilatasi massif/ kompartemen vaskuler, permeabilitas kapiler/ kebocoran cairaqn kedalam lokasi interstitial (ruang ketiga)

Tujuan : Menunjukkan perfusi adekuat yang dibuktikan dengan tanda-tanda vital sign stabil, nadi perifer jelas

Tindakan:

1. Catat haluaran urinarius setiap jam dan berat jenisnya

R : penurunan haluaran urin dengan peningkatan berat jenis akan mengindikasikan penuruynan perfungsi ginjal yang dihubungkan dengan perpindahan cairan dan vasokonstriksi relatif

2. Pantau TTV pasien

R : Memantau TTV pasien

3. Palpaasi denyut perifer

R : Denyut yang lemah , mudah hilang data menyebabkan hu[povolemia

4. Amati adanya udem pada tubuh

R : Kehilangan cairan dari kompertemen vaskuler kedalam ruang interstitial akan menyebabkan edema jaringan

5. Kaji turgor kulit

R : Hipovolemia akan memperkuat tanda-tanda dehidrasi

6. Berkan cairan IV

R : Dibutuhkan untuk mengatasi hipovolemia relatif

DAFTAR PUSTAKA

• Bruner dan Suddart ( 2001).Keperawatan Medikal Bedah, Jakarta : EGC
• Dongoes,M.E (1990). Rencana Asuhan Keperawatan ,Jakarta : EGC
• Hinchif ( 2005) Kamus Keperawatan, Jakarta

STIKes Hutama Abdi Husada Tulungagung                                                          

FORMAT PENGKAJIAN

776789

                                                                                                                                 DI INSTALASI GAWAT DARURAT

                                                                                                                                 NO. MR :

DATA IDENTITAS SOSIAL PASIEN

Nama Lengkap (Nama sendiri)		Sex	Umur /Tgl lahir
Tn. E		L	28 Th
Alamat Pasien (Menurut KTP/SIM)
No. KTP/SIM      :  0000001234789 Jln/Dsn                 : Dsn.tambak kembang Kel/Desa              : Ds. Tambakrejo Kec.                       : Sumbergempol Kodya/Kab.        : Tulungagung
Agama	Suku	Bangsa	Kasus Polisi
Islam	Jawa	Indonesia	-
Status Perkawinan	Jenis Pembayaran	Pendidikan	Pekerjaan
Kawin	Umum	SMA	Wiraswasta
Cara Datang		Transportasi ke IRD	Komunikasi
		Mobil	Baik
Kejadian tgl :   03/03/2014                   Jam :   19.30     WIB                           Di  Rumah
Datang di IRD tgl :  03/03/2014           Jam :   22.45      WIB
Keadaan Pra Hospitalisasi : GCS : 2 3 4         Tensi 140/90 mmHg,         Nadi : 97 x/mnt Pernafasan  : 25 x/mnt, Suhu  38,5 °C Tindakan Pra Hospital : RJP                           Infus  √                         Bebat                                  ETT                                    Penjahitan Trakeostomi             NGT                              Bidai                                  Pipa oro/naso O2  √                         Obat   √                        Kateter                               Suetion                               Pharingial Dll…………….                                             Urine
TRIAGE : Jam 22.50WIB oleh perawat Keluhan Utama  Px mengatakan kepalanya pusing,badan meriang dan panas,setiap makan mau muntah,dadanya sesak.		S.ax  : 38,5  °C S.rec : …………… °C	N : 97 x/mnt T : 140/90mmHg
		P : 25 x/mnt	(Pediatri) BB : 69 Kg
		Riwayat Penyakit : -          DM -          PJK                    - Dll -          Asma                 - Tidak ada  √
Riwayat Alergi :       Ya         Tidak √        Lain - lain		Kategori Triage : P1                P2    √            P3                PO
Keadaan Umum ; (Obyektif) : Baik                            Sedang                                 Buruk  √
-	Pernafasan : (B) Gerak  dada √ Simetris  √  Asunetris Pernafasan : (B) -          Normal -          Retractive -          Kusmaul -          Dangkal √ -          Trachypnoe	Sirkulasi : (C) N.Carotis :………./mnt N.Radial  :………./mnt Kulit Muskulo : -          Normal -          Jaundice -          Cyanosis √ -          Pucat√ -          Berkeringat -          Akral hangat	GCS : R.Mata      : 2 R.Verval   : 3 R.Motorik : 4 Total       : 9

Pemeriksaan Fisik (Assasment)                                                                         Keterangan : k/u lemah,cyanosis, thorak : cor : Mur mur (-),                 ekstremitas bawah : Odem                                5          5                                 5          5
Jam :	Pemeriksaan : Lab / Foto / ECG / Lain – lain Kultur SDP Elektrolit GDA EKG
Diagnosa : Sepsis
Jam 22.55	Terapi / Tindakan / Konsul Pemasangan infus,O2, Konsul obat	Jawaban / catatan
Jam keluar IRD : 6 JAM
Tindakan Lanjut KRS              MRS √               PP               D                Operasi             Pindah ke bag……..   Lain – lain ……….
Tanggal  : 03/03/2014 Nama Perawat : TRI WULAN SARI		Tanda Tangan

ANALISA DATA

Nama Pasien                      : Tn. E

Umur                                    : 28 Thn

No. Register                       :  776789

KELOMPOK DATA	MASALAH	KEMUNGKINAN PENYEBAB
Ds : Px mengatakan kepalanya pusing,badan meriang dan panas,setiap makan mau muntah,dadanya sesak. Do : k/u lemah,lemas,sianosis, sesak, TD : 140/90 mmHg N   : 97 x/mnt RR : 25 x/mnt S    : 38,5 0c Ds : Px mengatakan kepalanya pusing,badan meriang dan panas,setiap makan mau muntah,dadanya sesak. Do : k/u lemah,lemas,sianosis, sesak, TD : 140/90 mmHg N   : 97 x/mnt RR : 25 x/mnt S    : 38,5 0C	Gg. Pmenuhan O2 Gg.pmnuhan keb. Nutrisi	Infasi kuman ↓ Plpasan Indokrin ↓ Disfungsi dan krusakan endotel dan disfungsi organ multiple ↓ Sepsis ↓ Prubahan pngambilan dan pnyerapan O2 ↓ Suplai O2 terganggu ↓ Sesak ↓ Gg. Pmenuhan O2 Infasi kuman ↓ Plpasan Indokrin ↓ Disfungsi dan krusakan endotel dan disfungsi organ multiple ↓ Sepsis ↓ Terganggunya sistem pencernaan ↓ Reflek ingin muntah ↓ anoreksia ↓ Gg. Pmenuhan Nutrisi

DAFTAR DIAGNOSA KEPERAWATAN

Nama Pasien      : Tn. E

Umur                    : 28 Thn

No. Register       : 776789

NO	TANGGAL MUNCUL	DIAGNOSA KEPERAWATAN	TANGGAL TERATASI	TTD
1. 2.	03/03/2014 03/03/2014	Resiko tinggi terhadap kekurangan kebutuhan O2 b.d perubahan pengambilan dan penyerapan O2/ suplai O2 terganggu. Ds : Px mengatakan kepalanya pusing,badan meriang dan panas,setiap makan mau muntah,dadanya sesak. Do : k/u lemah,lemas,sianosis, sesak, TD : 140/90 mmHg N   : 97 x/mnt RR : 25 x/mnt S    : 38,5 0c  Resiko tinggi terhadap terganggunya pemenuhan kebutuhan nutrisi b.d gangguan sistem pencernaan /reflek ingin muntah. Ds : Px mengatakan kepalanya pusing,badan meriang dan panas,setiap makan mau muntah,dadanya sesak. Do : k/u lemah,lemas,sianosis, sesak, TD : 140/90 mmHg N   : 97 x/mnt RR : 25 x/mnt S    : 38,5 0C

RENCANA ASUHAN KEPERAWATAN

Nama pasien                      : Tn. E

Umur                                    : 28 Thn

No. Register                       : 776789

NO	DIAGNOSA KEPERAWATAN	TUJUAN	KRITERIA STANDART	RENCANA TINDAKAN	RASIONAL	TANDA TANGAN
1. 2.	Resiko tinggi terhadap kekurangan kebutuhan O2 b.d perubahan pengambilan dan penyerapan O2/ suplai O2 terganggu. Ds : Px mengatakan kepalanya pusing,badan meriang dan panas,setiap makan mau muntah,dadanya sesak. Do : k/u lemah,lemas,sianosis, sesak, TD : 140/90 mmHg N   : 97 x/mnt RR : 25 x/mnt S    : 38,5 0c  Resiko tinggi terhadap terganggunya pemenuhan kebutuhan nutrisi b.d gangguan sistem pencernaan /reflek ingin muntah. Ds : Px mengatakan kepalanya pusing,badan meriang dan panas,setiap makan mau muntah,dadanya sesak. Do : k/u lemah,lemas,sianosis, sesak, TD : 140/90 mmHg N   : 97 x/mnt RR : 25 x/mnt S    : 38,5 0C	Jangka pendek : setelah dilakukan tindakan keperawatan 1x 6 jam kebutuhan O2 terpenuhi Jangka panjang : setelah dilakukan tindakan keperawatan 1x 24 jam kebutuhan O2 terpenuhi sepenuhnya Jangka pendek : setelah dilakukan tindakan keperawatan 1x 6 jam kebutuhan nutrisi terpenuhi sebagian Jangka panjang : setelah dilakukan tindakan keperawatan 1x 24 jam kebutuhan nutrisi terpenuhi sepenuhnya	k/u baik tidak sianosis tidak sesak tidak ada retraksi dada/perut TTV normal : TD : 120/90 mmHg N : 80 x/mnt RR : 20x/mnt S : 36,5-370c k/u baik tidak muntah lagi tidak sianosis tidak lemas mukosa bibir tidak kering TTV normal : TD : 120/90 mmHg N : 80 x/mnt RR : 20x/mnt S : 36,5-370c	BHSP Obs. TTV Beri 02 nassa kanul Pantau k/u px Kolab tim medis BHSP Obs.TTV Obs.intake output Pantau k/u px Kolab tim medis	Membina hub.terapeutik antara pasien,kluarga dan perawat Untuk mengetahui k/u px Memenuhi keb.O2 Px Untuk mengetahui perkembangan px Mempercepat penyembuhan px Membina hub.terapeutik antara pasien,kluarga dan perawat Untuk mengetahui k/u px Mengetahui perkembangan intake output px Untuk mengetahui perkembangan px Mempercepat penyembuhan px

TINDAKAN KEPERAWATAN                                                                               CATATAN PERKEMBANGAN

Nama Pasien      : Tn. E                      Umur                  :  28 Thn                                 No. Register     :  776789                               Kasus  : Sepsis

NO	NO. DX	TANGGAL/ JAM	IMPLEMENTASI	TTD	TANGGAL/ JAM	E V A L U A S I	TTD
1. 2.	Dx `1 Dx 2	03/03/2014 22.50 22.55 23.00 23.05 03/03/2014 22.50 22.55 23.00 23.05	BHSP Memberikan O2 masker 10 lter/mnt TTV :  TD : 140/90 mmHg  N   : 97 x/mnt  RR : 18 x/mnt  S    : 38,5 0C Memberikan posisi semi flouler BHSP Memberikan O2 masker 10 ltr/mnt dan pemasangan infus RL 20tts/mnt TTV :  TD : 140/90 mmHg  N   : 97 x/mnt  RR : 18 x/mnt  S    : 38,5 0C Obs. Intake uotput		03/03/2014 23.15 03/03/2014 23.05	S : Px mengatakan tidak sesak lagi.tp masih merasakan pusing dan badan masih terasa panas O : k/u tdk sianosis lg,tidak sesak,terpasang O2 masker 10 ltr/mnit,terpasang infus Rl 20 tts/mnt A : Gg. Pmnuhan O2 terpenuhi P : Obs. TTV      Obs. k/u px      Obs. O2       Interfensi dilanjutkan S : px mengatakan tidak mual lagi,tidak  lemas. O : k/u tidak lemas lg,tidak mual,tidak sianosis A : Gg.pemenuhan keb.nutrisi terpenuhi sebagian P : Obs. TTV      Obs. k/u px      Kolab.tim medis      Interfensi dilanjutkan