PengKajiAn

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ASUHAN KEPERAWATAN PADA PASIEN An.Y DENGAN LEUKEMIC PHASE OF LYMPHOMA RUANG 7B RSU Dr. SAIFUL ANWAR MALANG I. PENGKAJIAN A. Identitas Klien Nama : Usia : Jenis Kelamin : Alamat : B. Status Kesehatan Saat Ini 1. Keluhan saat MRS :......................................................... 2. Keluhan saat Pengkajian : 3. Riwayat Penyakit Sekarang : Nama Mahasiswa :Andi Wahid Kahar NIM : 201420461011109 Tempat Praktik : Tgl Praktik : No.RM : Tgl.MRS : Tgl Pengkajian : Sumber informasi : ................................................................. ................................................................. ................................................................. ................................................................. ................................................................. ................................................................. ................................................................. ................................................................. ................................................................. ................................................................. ................................................................. .................................................................

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ASUHAN KEPERAWATANPADA PASIEN An.Y DENGAN LEUKEMIC PHASE OF LYMPHOMA RUANG 7B RSU Dr. SAIFUL ANWAR MALANGI. PENGKAJIANA. Identit! K"ienNama : Usia : Jenis Kelamin : Alamat : B. Stt#! Ke!e$tn St Ini%. Ke"#$n !t MRS &.........................................................'. Ke"#$n !t Pen()*in : .................................................................................+. Ri,-t Pen-)it Se)rn( &N. M$!i!, :Andi Wahid KaharNIM : 201420461011109Te./t Pr)ti): T(" Pr)ti) : No.RM : Tl.MR! : Tl "en#a$ian :!%m&er in'ormasi : ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................C. Di(n0! Medi! &D. RIWAYAT KESEHATAN TERDAHULU 1. "en(a#it (an )ernah dialami :....................................................................................................................................................................................................................................2. Ke*ela#aan +,a(i-ana#: termas%##e*ela#aanlahir-)ersalinan.,ila )ernah: $enis dan /a#t%. sia)a )enolon #elahirann(a0 :....................................................................................................................................................................................................................................1. Ri/a(at )re. intra. dan )ost natal: a. "re natal...................................................................................................................................................................................................................................................................................................&. Intra natal....................................................................................................................................................................................................................................................................................................*. "ost natal...................................................................................................................................................................................................................................................................................................4. 2)erasi +Jenis dan Wa#t%0: ........................................................................................................................................................3. Ri/a(at aleri: ........................................................................................................................................................6. "en(a#it #ronis-a#%t : ........................................................................................................................................................4. Tera#hir #ali MR! : ........................................................................................................................................................5. Im%nisasi :a. ,67 + 0&. 6am)a# + 0*. 8"T + 0 e. 9e)atitis + 0d. "olio + 0 E. RIWAYAT KESEHATAN KELUARGA1. "en(a#it (an )ernah diderita #el%ara:................................................................................................................................................................................................................................................................................................................2. :in#%nan r%mah dan #om%nitas:................................................................................................................................................................................................................................................................................................................1. "erila#% (an mem)enar%hi #esehatan:................................................................................................................................................................................................................................................................................................................4. "erse)si #el%ara terhada) )en(a#it ana#:................................................................................................................................................................................................................................................................................................................3. Ri/a(at aleri................................................................................................................................................................................................................................................................................................................F. POLA NUTRISI1METABOLIKItem 8es#ri)si8i R%mah 8i R%mah !a#itJenis diet-ma#anan-Kom)osisi men%;re#%ensi-)ola"orsi-$%mlah"antananNa's% ma#an"enin#atan-"en%r%nan,, 6 &%lan tera#hir!%#ar menelanG. "2:A la#i : )erem)%an : )asien : tinal ser%mah : meninalM. PEMERIKSAAN FISIKT8?-mm9 RR ?@-mntN? @-menit ,, ?#!%h%? A6", ?*mKeadaaan Um%m: Ke)ala dan :eher%. Ke/": normo*he)al + 0. lesi + 0. &en$olan + 0.ram&%t /arnahitam ti)is + 0. )erse&aran merata + 0'. Mt:simetris 8-!+0. anemis+08-!.)%)il iso#or+0.rea#si terhada) *aha(a + - 0. s#lera )%tih+ 0. i#teri#+ 0.+. Hid#n(:)oli) + 0.n(eri + 0. N7T + 0. ter)asan 22 N6 + 0.)erna'asan *%)in hid%n + 0. lesi + 0.2. M#"#t dn Ten((0r0)n: M%#osa &i&ir #erin+0. lesi +0.hi)ersaliBasi + 03. Te"in(:!imetris 8-!+0.&en$olan+ 0.n(eri+ 0.iritasi+ 0ser%men + 0.)eradanan + 0. '%nsi )endenaran + 04. Le$er: JC8 + 0. )em&esaran #elen$ar lim'e + 0. lesi + 0. &ent%#simetris + 0. tra#ea di tenah+ 0.7. DdIn!/e)!iBent#) t$0r)n0r."5$e!t+06 !i.etri!+06 d retr)!i dindin(dd+ 06 n7! 5e/t dn d".+ 06 /erdn(n 8 9P"/!i .!!+ 06 n-eri te)n 8 9Per)#!i S0n0rA%s#%ltasi "ar%S#r N7! De!)ri/!iD ,ron#ial >D ,ron#oBesi#%ler >D Cesi#%lerS#r U5/n 1 1Br0n)0/0ni:Pe5t0r-"0;#-:E(0/$0ni > >S#r T."%lmon%m "%lsasi:>Area tri*%s)id>Centri#el #anan "%lsasi:>:eta# I*t%s 6ordis Tera&a I6! C mid*laBi*%lar line"er#%si,atas $ant%nI6! )arastern%m de@traKesadaran:66!: I6!. )arastern%mI6! )arastern%m sinistra!%araA%s#%ltasi,%n(i Jant%n I,%n(i Jant%n II,%n(i Jant%n III M%rm%r + 0. allo) + 0,%n(i Jant%n IC >Kel%han>. P#n((#n( &:esi+ 0.Massa+ 0.Radan+ 0.Kelainan t%lan &ela#an+ 0?. M.e dn A@i"& ,en$olan-massa + 0 N(eri: + 0%A. A4 @-menit"al)asiD !*i&ala+ 0D "em&esaran 9ati + 0"er#%si Thim)ani+ 0:ain>lain%%. Genet"i"en#a$ian 8ata-7e$ala 8es#ri)siIns)e#si :esi+ 0!*ar + 0 Massa+ 0 8istensi+ 0"al)asiN(eri te#an + 0Kel%han:ain>lain%' E)!tre.it!AtasD :esiD !*ar D Kontra#t%r D 8e'ormitas D 0.edema+>0. n(eri te#an+>0. *l%&&in 'iner+>0.ter)asanin'%s di tanan #iri,a/ahD :esiD !*ar D Kontra#t%r D 8e'ormitas D 0. n(eri+>0. #ontra#t%r+>0. de'ormitas +>0Ke#%atan2totD 0"te#ie: +>0N. 8ATA "