Laporan Pendahuluan Vulnus Appertum

LAPORAN PENDAHULUAN ASUHAN KEPERAWA KEPERAWATAN PADA KLIEN DENGAN D ENGAN VULNUS APPERTUM

A. Definisi •

Luka : adala ilan! a"au #usakn$a se%a!ian &a#in!an "u%u

•

Vulnus Vulnus a''e#"u( a''e#"u( adala luka den!an "e'i $an! "idak %e#s"u#an %e#s"u#an a"au )*('an!+)a('in! )*('an!+)a('in!  %iasan$a ka#ena "a#ikan a"au !*#esan %enda "u('ul

•

Vulnus a''e#"u( adala luka #*%ek (e#u'akan luka "e#%uka $an! "e#&adi keke#asan "u('ul $an! kua" sein!!a (ela('aui elas"isi"as kuli" a"au *"*"

,. Klasifikasi Luka -. Eksk*#iasi a"au luka le)e" .

Vulnus s)isu( s)isu( a"au luka sa$a" aki%a" %enda % enda "a&a(. Pin!!i# lukan$a "e#lia" #a'i

/.

Vulnus lase#a"u( a"au luka #*%ek aki%a" "e#kena (esin a"au %enda laiin$a $an! (en$e%a%kan #*%ekn$a &a#in!an #usak dala(

0.

Vulnus 'un)"u( a"au luka "usuk 

1.

Vulnus (*#su( (*#su( a"au luka ka#ena !i!i"an %ina"an!

2.

Vulnus )*(%*"i* a"au luka %aka# 

3.

Vulnus )*n"usu( a"au luka (e(a# ka#ena )ide#a 'ada &a#in!an % a4a kul" aki%a" %enda "u('ul

5.

Vulnus Vulnus s)l*'e"*#u( s)l*'e"*#u( a"au luka "e(%ak 6Hida$a" 6Hida$a" ali(ul a7i78 9958 ke"#a('ilan ke"#a('ilan dasa# un"uk   '#ak"ik klinik ke%idanan8 &aka#"a sale(%a (edika 

;. E"i*l*!i -. Ke)elakaan . ,enda ,enda #un #un)i )in! n! a"a a"au u %enda %enda "a& "a&a( a( /. ,end ,endaa "u( "u('ul 'ul 0. Gi!i Gi!i"a "an n %ina %ina"a "an! n!

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1. Pe#an!

D. G#anulasi : Te#&adi (ulai aki# fase infla(asi sa('ai aki# (in!!u ke /. Pada fase ini luka di'enui sel #adan!8 fi%#*%las" dan k*la!en8 (e(%en"uk &a#in!an %e#4a#na ke(e#aan den!an 'e#(ukaan $an! %e#%en&*l alus $an! dise%u" &a#in!an !#anulasi. P#*ses ini %a#u %e#en"i se"ela e'i"el salin! (en$en"u dan (enu"u' selu#u 'e#(ukaan luka. /. (eni" Skala n$e#i 2 Ansie"as

•

• • •

DS  'asien (en!a"aka "aku" kalau  %ekas luka ea)"in! "idak %isa se(%u se'e#"i kuli" %iasa DO Te#da'a" Te#da'a" luka %ekas ea)"in! Luka "e#"u"u' kassa  Nadi -99B(

E"i*l*!i #asa Ke#usakan k*n"inui"as &a#in!an

Ku#an!n$a  'en!e"auan "en"an!  '#*ses  'en$e(%uan luka

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INTERVENSI INTE RVENSI KEPERAWA KEP ERAWAT TAN T!l   N* -

Dia!n*sa ke'e#a4a"an

Tu&uan dan K#i"e#ia Hasil

Gan!! n!!uan #a #asa n$ n$a(a a(an n$ n$e#i %e %e#u% u%un!a n!an de den!an

Tu&uan : N$e#i %e#ku#an!8

ke#usakan k*n"inui"as &a#in!an

K#i"e#ia :

-. ,in . k  in"

•

Klien "idak (en!elu n$e#i.

•

Pe(%en!kakan ilan! a"au %e#ku#an!. /. A&

•

T"= dala( %a"as n*#(al

"e 0. O 1. K  2. ,e 3. K 

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T!l   N* 

Dia!n*sa Ke'e#a4a"an

Tu&uan dan K#i"e#ia Hasil

;e(as %e %e#u%u!an !an de den!an ku ku#an!n$a n$a 'e 'en!e"aua auan n

Tu&uan uan : )e(a e(as %e# %e#ku#a u#an! K#i"e#ia :

-. ,ina . O%s

•

Te#da'a" Te#da'a" luka %ekas ea)"in!

/. ,e#i

•

Luka "e#"u"u' kassa

0. ,e#i

•

T"= dala( %a"as n*#(al

•

Pasien "idk la!i %e#"an$a

1. O%s

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TINDAKAN KEPERAWATAN  N* . -.

T!l. -1>1> 9-

a(

Tindakan Ke'e#a4a"an -. Me(%ina u%un!an salin! 'e#)a$a . Men!ka&i keadaan n$e#i8 n$e#i 'ada luka di 'aa8 skala n$e#i 2 /. Men!a&a#kan 'asien "enik #elaksasi nafas dala( dan "enik  dis"#aksi un"uk (en!u#an!i #asa saki" 0. O%se#=asi =i"al si!n Tensi -99>39 ((!  Nadi -99B>(ni" 1. K*la%*#asi dala( 'e(%e#ian "e#a'i anal!esik ke"*#*la) /B/9



(! 2. Me(%e#ikan He en"an! '#*sedu# 'elaksaan "indakan ea)"in! 3. K*la%*#asi dala( "indakan ea)"in!

-. Me(%ina u%un!an salin! 'e#)a$a . (en!*%se#=asi (en!*%se#=asi 'en$e%a% )e(as8 $ai"u $ai"u 'asien 'asien "aku" kalau %ekas luka "idak %isa se(%u s'e#"i se(ula /. (e(%e#ikan He "en"an! '#*sedu# 'elaksanaan "indakan (edis 0. (e(%e#ikan He "en"an! '#*ses 'en$e(%uan luka 1. O%se#=asi =i"al si!n Tensi -99>39 ((!

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 N * -.

T!l. -1>1>9

Dia!n*s a -

;a"a"an Pe#ke(%an!an S : Pasien (en!elu n$e#i O

•

Te#da'a" Te#da'a" luka "e#%uka 'ada 'aa 'a a kanan seki"a# 2 )(

•

Wa&a Wa &a "a('ak kesaki"an

•

•

 Nadi -99B>(eni" Skala n$e#i 2 A: !an!!uan #asa n$a(an n$e#i P: Te#uskan Te#uskan #en)ana in"e#=ensi.

.

S  'asien (en!a"aka "aku" kalau %ekas luka ea)"in! "idak %isa se(%u se'e#"i kuli" %iasa

• • • •

O Te#da'a" Te#da'a" luka %ekas ea)"in! Luka "e#"u"u' kassa  Nadi -99B( Pasien %e#"an$a "en"an! %ukas luka $an! ada A: ;e(as P: Te#uskan Te#uskan #en)ana in"e#=ensi.