ASUHAN KEPERAWATAN

PADA KASUS KMB

Hella Meldy Tursina. S.Kep., Ns.M.Kep

DOMAIN 2-NUTRITION
 DOMAIN 2; CLASS 1
INGESTION
 OBESITAS
 OVERWEIGHT
 RISK FOR OVER WEIGHT
 IMPAIRED SWALLOWING (GANGGUAN MENELAN)
 DOMAIN 2; CLASS 4
METABOLISM
 RISK FOR UNSTABLE BLOOD GLUCOSE LEVEL
 RISK FOR IMPAIRED LIVER FUNCTION
 RISK FOR IMPAIRED METABOLIC IMBALANCE SYNDROME
 DOMAIN 2; CLASS 5
HYDRATION
 RISK FOR IMBALANCED FLUID VOLUME
 RISK FOR ELECTROLY TE IMBALANCED
 DEFICIENT FLUID VOLUME
 EXCESS FLUID VOLUME
DOMAIN 3- ELIMINATION
AND EXCHANGE
 DOMAIN 3 CLASS 1
URINARY FUNCTION
 IMPAIRED URINARY FUNCTION
 FUNCTIONAL URINARY INCONTINENCE
 OVERFLOW URINARY INCONTINENCE
 REFLEX URINARY INCONTINENCE
 STRESS URINARY INCONTINENCE
 URGE URINARY INCONTINENCE
 RISK FOR URGE URINARY INCONTINENCE
 URINARY RETENTION
 DOM 3; CLASS 2
GRASTROINTESTIAL FUNCTION
 CONSTIPATION
 RISK FOR CONSTIPATION
 PERCEIVED CONSTIPATION
 CHRONIC FUNCTIONAL CONSTIPATION
 RISK FOR CHRONIC FUNCTIONAL CONSTIPATION
 DIARRHEA
 DYSFUNCTIONAL GASTROENTESTINAL MOTILIT Y
 RISK FOR DYSFUNCTIONAL GASTROENTESTINAL MOTILIT Y
 BOWEL INCONTINENCE
 DOM 3; CLASS 4
RESPIRATORY FUNCTION
 IMPAIRED GAS EXCHANGE
DOMAIN 4- ACTIVITY
AND REST
 DOM 4,CLASS 1
SLEEP /REST
 INSOMNIA
 SLEEP DEPRIVATION
 READINESS FOR ENHANCED SLEEP
 DISTURBED SLEEP PATTERN
 DOM 4,CLASS 2
ACTIVIT Y/EXERCISE
 RISK FOR DISUSED SYNDROME
 IMPAIRED BED MOBILIT Y
 IMPAIRED PHYSICAL MOBILIT Y

YANG LAIN MASUK KASUS: KDM

IMPAIRED SITTING, STANDING DLL
 DOM 4,CLASS 3
ENERGY BALANCE
 IMBALANCED ENERGY FIELD
 FATIGUE

 WANDERING : JIWA
 DOM 4,CLASS 4
CARDIOVASCULAR/PULMONARY
RESPONSES
 ACTIVIT Y INTOLERANSI
 RISK FOR ACTIVIT Y INTOLERANCE
 INNEFFCETIVE BREATHING PATTERN
 DECREASED CARDIAC OUTPUT
 RISK FOR DECREASED CARDIAC OUTPUT
 IMPAIRED SPONTANEUS VENTILATION (KEP. KRITIS)
 RISK FOR UNSTABLE BLOOD PRESSURE
 RISK FOR DECREASED CARDIAC TISSUE PERFUSSION
 RISK FOR INNEFFECTIVE CEREBRAL TISSUE PERFUSSION
 INNEFFECTIVE PERIPHERAL TISSUE PERFUSSION
 DYSFUNCTIONAL VENTILATORY WEANING RESPONSE (KRITIS)
 DOM 4 CLASS 5
SELF CARE
 MASUK KEPERAWATAN DASAR
 IMPAIRED HOME MAINTENANCE
 BATHING SELF CARE
 DRESSING
 FEEDING
 TOILETTING
 READINESS FOR ENHANCED SELF CARE
 SELF NEGLECTED
 DOMAIN 5-
PERSEPSI/KOGNISI
 D5-C4
KOGNISI
 ACUTE CONFUSSION
 RISK FOR ACUTE CONFUSSION
 CHRONIC CONFUSSION
 IMPAIRED MEMORY
DOMAIN 8- SEXUALITY
 D8-C 2
SEXUAL FUNCTION
 SEXUAL DYSFUNCTION
 INNEFFECTIVE SEXUALIT Y PATTERN
D9-COPING STRESS
TOLERANCE
 D9, C2
COPING RESPONSES
 DEATH ANXIET Y
 CHRONIC SORROW
 D9-C3
NEUROBEHAVIORAL STRESS
 ACUTE SUBSTANCES WITHDRAWL SYNDROME
 RISK FOR ACUTE SUBSTANCES WITHDRAWL SYNDROME
DOMAIN 11-SAFETY
PROTECTION
 D11-C2
INFECTION
 RISK FOR INFECTION
 RISK FOR SURGICAL SITE INFECTION
 D11-C C2
PHYSICAL INJURY
 INNEFFECTIVE AIRWAY CLEARENCE
 RISK FOR ASPIRATION
 RISK FOR BLEEDING
 RISK FOR DRY EYE
 RISK FOR DRY MOUTH
 RISK FOR FALLS
 RISK FOR CORNEAL INJURY
 RISK FOR INJURY
 RISK FOR URINARY TRACT INJURY
 RISK FOR PERIOPERATIVE POSITIONING INJURY
 RISK FOR THERMAL INJURY
 D11-C C2
PHYSICAL INJURY
 IMPAIRED ORAL MUCOUS MEMBRANE INTEGRIT Y
 RISK FOR IMPAIRED ORAL MUCOUS MEMBRANE INTEGRIT Y
 RISK FOR PERIPHERAL NEUROVASCULAR DYSFUNCTION
 RISK FOR PHYSICAL TRAUMA
 RISK FOR VASCULAR TRAUMA
 RISK FOR PRESSURE ULCER
 IMPAIRED SKIN INTEGRIT Y
 RISK FOR IMPAIRED SKIN INTEGRIT Y
 RISK FOR SUFFOCATION
 DELAYED SURGICAL RECOVERY
 RISK FOR DELAYED SURGICAL RECOVERY
 D11-C C2
PHYSICAL INJURY
 IMPAIRED TISSUE INTEGRIT Y
 RISK FOR IMPAIRED TISSUE INTEGRIT Y
 RISK FOR VENOUS THROMBOEMBOLISM
 D11-C4
ENVIRONMENTAL HAZARDS
CONTAMINATION
 RISK FOR CONTAMINATION
 RISK FOR OCCUPATIONAL INJURY
 RISK FOR POISONING
 D11-C5
DEVENSIVE PROCESSES
 RISK FOR ADVERSE REACTION TO IODINATED CONTRAST
MEDIA
 RISK FOR ALLERGY REACTION
 RISK FOR LATEX ALLERGY REACTION
 D11-C6
THERMOREGULATION
 HYPERTHERMIA
 HYPOTHERMIA
 RISK FOR HYPOTHERMIA
 RISK FOR HYPERTERMIA
 RISK FOR PERIOPERATIVE HYPOTHERMIA
 INNEFFECTIVE THERMOREGULATION
 RISK FOR INNEFFCETIVE THERMOREGULATION
DOMAIN 12- COMFORT
 D 12-C1
PHYSICAL COMFORT
 NAUSEA
 ACUTE PAIN
 CHRONIC PAIN
 CHRONIC PAIN SYNDROME