Laporan Pendahuluan & Asuhan Asuhan Keperawatan Pasien LUKA BAKAR
Oleh: Kelompok 2
SEKOLAH TINGGI ILMU KESEHATAN SURYA MITRA HUSADA PROGRAM STUDI PENDIDIKAN NERS KEDIRI 2015
Latar Belakang
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Dalamnya luka bakar.
Kedalaman
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Berat ringannya luka bakar
U%$uk me%&k+' !e"$%) luk !k" h"u( #'pe"$'m!%&k% !e!e"p *k$o" %$" l'% : 1-
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Ameri!an Burn Asso!iation membagi dalam "
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Y%& $e"m(uk luk !k" "'%&% m'%o"6 : T'%&k$ II
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ku"%& #"' 15/ To$l 4o#) Su"*,e A"e p# o"%&
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Y%& $e"m(uk luk !k" (e#%& mo#e"$e6 : T'%&k$ II
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15/ ; 25/ To$l 4o#) Su"*,e A"e p# o"%& #e(
$u ku"%& #"' 10/ ; 20/ To$l 4o#) Su"*,e A"e p# %k3%kT'%&k$ III
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Ameri!an !ollege o# surgeon membagi dalam"
Parah – critical: •
T'%&k$ II
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T'%&k$ III
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T'%&k$ II
: 15 ; <0/
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T'%&k$ III
: 1 ; 10/
Ringan – minor: •
T'%&k$ II
: ku"%& 15/
•
T'%&k$ III
: ku"%& 1/
Pato#isiologi
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$mpk%) (e," pe"ku$% #% ke"u(k% +"'%&% #p$ !e"l%+u$ (mp' 2 +m (e$elh ,e#e"8e#e" l'($"'k: ,e#e" ku$%eu( ek($e"%l !'(%) le!'h (e#'k'$ #' !h %ek"o('(Pe%mp'l% luk !e">"'(' #p$ mel'pu$' luk l'"% m(ukkelu" ek(plo('*6. luk !k" #"' &e"k% l'"% p# p"ok('ml $u!uh $e"$u$up #% luk !k" $e"ml (ehu!u%&% #e%&% pk'% $e"!k"A#%) *"k$u"#'(lok(' +$uh. ke,elk% (epe# mo$o". ko%$"k(' o$o$ $e$%'k (ehu!u%&% #e%&% ()ok l'($"'k6 Pemeriksaan diagnostik: 1-
LED: me%&k+' hemoko%(e%$"('-
2-
Elek$"ol'$ (e"um me%#e$ek(' ke$'#k(e'm!%&% ,'"% #% !'ok'm'- I%' $e"u$m pe%$'%& u%$uk meme"'k( kl'um $e"#p$ pe%'%&k$% #lm 29 +m pe"$m k"e% pe%'%&k$% kl'um #p$ me%)e!!k% he%$' +%$u%&-
<-
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9-
4UN #% k"e$'%'% me%&k+' *u%&(' &'%+l-
5-
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-
K#" k"!o% mo%ok('# (e"um me%'%&k$ p# ,e#e" '%hl(' (p-
Diagnosa Keperawatan
Se!&'% kl'e% luk !k" #p$ $e"+#' D'&%o( U$m #% D'&%o( Tm!h% (elm me%#e"'$ luk !k" ,ommo% %# ##'$'o%l6- D'&%o('( )%& l'm $e"+#' p# kl'e% )%& #'"$ #' "umh (k'$ )%& me%#e"'l luk !k" le!'h #"' 25 / To$l 4o#) Su"*,e A"e : 1-
Pe%u"u%% K"#'k Ou$pu$ !e"hu!u%&% #e%&% pe%'%&k$% pe"m'!'l'$( kp'le"-
2-
De*'('$ Bolume 8'"% !e"hu!u%&% #e%&% ke$'#k (e'm!%&% elek$"ol'$ #% keh'l%&% >olume pl(m #"' pem!uluh #"h-
<-
Pe"u!h% Pe"*u(' ="'%&% !e"hu!u%&% #e%&% Pe%u"u%% K"#'k Ou$pu$ #% e#em-
9-
Ke$'#ke*ek$'*% Pol N*( !e"hu!u%&% #e%&% ke(uk"% !e"%*( Re(p'"$o") D'($"e((6 #"' $"um '%hl('. (um!$% O!($"uk('6 +l% %*( #% p%eumo%'-
5-
Pe"u!h% R( N)m% : N)e"' !e"hu!u%&% #e%&% pp"% u+u%& ()"* p# kul'$ )%& "u(k-
@-
G%&&u% I%$e&"'$( Kul'$ !e"hu!u%&% #e%&% luk !k"-
-
Po$e%('l I%*ek(' !e"hu!u%&% #e%&% &%&&u% '%$e&"'$( kul'$-
-
Pe"u!h% Nu$"'(' : Nu$"'(' Ku"%& #"' Ke!u$uh% Tu!uh !e"hu!u%&% #e%&% pe%'%&k$% "$3"$ me$!ol'(me-
-
G%&&u% Mo!'l'$( 7'('k !e"hu!u%&% #e%&% luk !k". (," #% ko%$"k$u"-
10-
G%&&u%
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Re('ko $'%&&' !e"('h% +l% %*( $'#k e*ek$'* !e"hu!u%&% #e%&% o!$"uk(' $"ke!"o%k'lJe#em muko( #% h'l%&%) ke"+ ('l'- Luk !k" #e"h lehe"J komp"e(' +l% %*( $ho"k #% ## $u ke$e"#$(% pe%&em!%&% ##-
2-
Re('ko $'%&&' keku"%&% >olume ,'"% !e"hu!u%&% #e%&% Keh'l%&% ,'"%
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9-
Re('ko $'%&&' '%*ek(' !e"hu!u%&% #e%&% Pe"$h%% p"'me" $'#k #eku$J ke"u(k% pe"l'%#u'%&% kul'$J +"'%&% $"um$'k- Pe"$h%% (eku%#e" $'#k #eku$J pe%u"u%% H!. pe%ek%% "e(po%( '%*lm('-
5-
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@-
Re('ko
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Pe"u!h% %u$"'(' : Ku"%& #"' ke!u$uh% $u!uh !e"hu!u%&% #e%&% ($$u( h'pe"me$!ol'k (e!%)k 50 / ; @0/ le!'h !e(" #"' p"opo"(' %o"ml p# ,e#e" !e"$6 $u k$!ol'(me p"o$e'%-
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Ku"%& pe%&e$hu% $e%$%& ko%#'('. p"o&%o('( #% ke!u$uh% pe%&o!$% !e"hu!u%&% #e%&% Slh '%$e"p"e$(' '%*o"m(' T'#k me%&e%l (um!e"
Rencana Intervensi
'%*o"m('Ren!ana Keperawatan Diagnosa Keperawatan
%u/uan dan Kriteria
8nter'ensi
4asil
1- Re('ko !e"('h%
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