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8/17/2019 Askep Ibu Tukinadi
1/13
ASUHAN KEPERAWATAN KELUARGA Ny.TK
DENGAN PASCA PERAWATAN GE DEHIDRASI BERAT
DI DUSUN GAMPING TENGAH
RT 01 RW14 AMBARKETAWANG SLEMAN
JOGJAKARTA
Disusun untuk memenuhi salah satu tugas praktek profesi Ners
Mata Kuliah Keperawatan Keluarga
Oleh:
ABDUL AZIS
!"!##$%$"&IK"!%
'(O)(AM S*UDI ILMU K&'&(A+A*AN
,AKUL*AS K&DOK*&(AN U)M
-O)-AKA(*A
./
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ASU0AN K&'&(A+A*AN K&LUA()A N12 *K
'AS3A '&(A+A*AN )& D&0ID(ASI B&(A*
'&N)KA4IAN K&'&(A+A*AN
Hari/ta!!a" # J$%at&' M(i )00*
O"(+ # A,-$" Ai
M(t-( # Waa2ara& ,(r3ai -a (%(ri5aa 6ii5
!2 DA*A K&LUA()A
1. I-(tita K("$ar!a
a. Na%a KK # Ny. TK
,. J(i K("a%i # P(r(%$a
2. U%$r # 70 ta+$
-. P(-i-i5a # SD Ti-a5 Ta%at
(. A!a%a # I"a%
6. P(5(r8aa # 9
!. A"a%at # RT 01 RW 14
D$$ Ga%i! T(!a+
A%,ar5(taa!& Ga%i!& S"(%a
+. S$5$/5(,a!aa # Jaa/I-(ia
i. J$%"a+ a!!ta 5("$ar!a # 7 ra!
). S$$a a!!ta 5("$ar!a
N Na%a $%$r S(: H$, -! KK P(-- P(5(r8aa K(t
1
)
*
4
S-r.WD
S-r.DW
S-r.TS
S-r.SR
)' t+
); t+
)* t+
)0 t+
L5
L5
L5
L5
Aa5
Aa5
Aa5
Aa5
SMP
SD
SMP
MAN
B$r$+
Sata
Sata
P("a8ar
S(+at
S(+at
S(+at
S(+at
*. Ti( 5("$ar!a
J(i 5("$ar!a ii a-a"a+ Single parent family ya! t(r-iri -ari I,$
-a aa59aa5.
)
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4. G(!ra%
K(t(ra!a #
# P(r(%$a # Ny. TK
# La5i9"a5i # M(i!!a"
# Gari P(r5aia
# Gari K(t$r$a
# Ti!!a" -a"a% at$ r$%a+
7. S$5$ Ba!a -a A!a%a
K("$ar!a Ny. W (%$aya $5$ 8aa a"i -a %ai+ %(%(!a!
a-at 5(,iaaa 8aa ya! -ita%a55a -(!a +$,$!a 5("$ar!a
ya! %ai+ 5$at. S(%$a a!!ta 5("$ar!a ,(ra!a%a I"a%.
;. Stat$ Sia" E5%i K("$ar!a
P(!+ai"a 5("$ar!a Ny. TK (,(ar R.. A5ti6ita R(5r(ai
K("$ar!a ti-a5 %(%$yai 8a-a" r(5r(ai ya! t(rat$r& 5ar(a
aa5ya $-a+ -(aa -a %("a5$5a r(5r(ai (-iri9(-iri
5("$ar!a %(%a6aat5a a5t$ "$a! $t$5 %(t t("(3ii.
.2 (iwa1at 5an *ahap 'erkem6angan Keluarga
1. Ta+a P(r5(%,a!a K("$ar!a Saat Ii
*
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K("$ar!a Ny.TK aat ii t(r%a$5 -a"a% tara6 (r5(%,a!a
5("$ar!a -(!a aa5 r(%a8a/(%$-a.
). Ta+a P(r5(%,a!a K("$ar!a ya! B("$% T(r($+i
S(2ara $%$% ti-a5 a-a %aa"a+ -a"a% ta+a (r5(%,a!a
5("$ar!a aat ii.
*. Riayat K((+ata K("$ar!a Iti
N12*K
K("$ar!a %(!ata5a ,a+a Ny.TK a-a ta!!a" 1< Ari" )00*
%(!("$+ %(2r(t -a %$ta+9%$ta+ a%ai ta5 a-ar5a -iri.
K(%$-ia "(+ 5("$ar!a Ny.TK -i,aa 5( R$%a+ Sa5it Sar8it
-a -iraat ("a%a 1 %i!!$ -(!a -ia!( GE D(+i-rai
B(rat. Ny.TK ti-a5 %(!(ta+$i (2ara ati (y(,a, ,("ia$
%$ta+ %(2r(t. S("a%a -i RS %(-aat t(rai I6$ -a ,at9
,at ra" ?Ny.TK ti-a5 ta+$ a%aya@.
Pa-a aat (!5a8ia Ny.TK ta%a5 %ai+ "(%a+ TD 110/>0
%%H!& Na-i 100:/%(it BB 41 K!& t$r!r 5$"it ,ai5& (rita"ti5
$$ r%a"& %$a"?9@&5(%,$!?9@ 5("$+a "ai ta5 a-a.
S5r2 +D7S5r S5r2 *S 5an S5r S(
Ny.TK %(!ata5a ,a+a aa5ya (+at (+at a8a ti-a5 (ra+
%(-(rita $at$ (ya5it ya! ara+.
4. Riayat P(ya5it K("$ar!a
a. Riayat (ya5it -a+$"$
Ny. TK %(!ata5a ,a+a -ia ti-a5 (ra+ %(-(rita
(ya5it ya! ara+ (8a5 -a+$"$ -(%i5ia $"a -(!a
aa59aa5ya.
,. P(ya5it 5(t$r$a
M($r$t 5("$ar!a Ny.TK ,a+a ti-a5 a-a (ya5it
5(t$r$a -ari i+a5ya (-a!5a $a%iya %(i!!a"
5ar(a a5it tr5( -a "i3(r.
2. P(ya5it 5ri/%($"ar
4
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Ny.TK %(!ata5a ,a+a ti-a5 a-a a!!ta 5("$ar!a ya!
%(-(rita (ya5it %($"ar.
-. K(2a2ata a!!ta 5("$ar!a
Ti-a5 a-a a!!ta 5("$ar!a ya! %(!a"a%i 2a2at 6ii5& .
(. P(%a6aata ai"ita K((+ata
K("$ar!a %(!ata5a ,i"a a!!ta 5("$ar!a a5it -i,("i5a
,at t(r"(,i+ -a+$"$ -a ,i"a ti-a5 a-a (r,ai5a ,ar$
,(r,at 5( -5t(r..
7. Riayat K((+ata M(ta"& Pi5"!i& Sirit$a".
- K("$ar!a Ny.TK %(raa a%a ti!!a" -i r$%a+ aat ii& 5ar(a
"i!5$!a ya! a%a -a t(ta!!a ,ai5.
- Riayat irit$a" a!!ta 5("$ar!a
S(%$a a!!ta 5("$ar!a taat ,(ri,a-a+& 5(!iata 5(a!a%aa
-i 5a%$! ,(r$a (!a8ia -ii5$ti r$ti "(+ Ny.TK.
- Ga!!$a %(ta" -a i5"!i a!!ta 5("$ar!a
Ti-a5 a-a a!!ta 5("$ar!a ya! %(raa t(rt(5a ata$
%(!a"a%i !a!!$a %(ta"& 5%$i5ai atar a!!ta
5("$ar!a +ar%i .
;. P(r(i -a Ta!!aa K("$ar!a t(r+a-a Layaa K((+ata.
Ta!!aa K("$ar!a T(r+a-a Layaa K((+ata ,a+aaya
5((+ata it$ (ti! t(r,$5ti ,i"a a!!ta 5("$ar!a a5it Ny.TK
%(!a8$r5a $t$5 (!(ra ,(r,at.
>. P"a P(!a%,i"a K($t$a
S(tia a-a %aa"a+ ("a"$ -i%$yaara+5a $t$5 %(!a%,i"
5($t$a& ,iaaya i,$ ya! -%ia -a"a% %(!a%,i"
5($t$a.
8/17/2019 Askep Ibu Tukinadi
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8ara! %a5a ,(ra%a9a%a 5ar(a a5t$ %a5a
%(y($ai5a -(!a a5ti6ita %ai!9%ai!.
,. Mi$%
S(%$a a!!ta 5("$ar!a %(%$yai 5(,iaaa %i$% air
$ti+ ya! $-a+ -i%aa5 rata9rata ; = < !("a (r +ari.
2. Cara %(!"a+ %a5aa
Ny.TK %(%aa5 (-iri %a5aaya& 2ara %(%aa5 ay$ra
,iaaya -it! ,ar$ -i2$2i. Air %i$% -ari $%$r -a
("a"$ -i%aa5 "(,i+ -a+$"$.
-. Cara (ya8ia
Ma5aa ya! $-a+ %aa5 -ii%a a-a t(%atya -a
ya! a5a %a5a %(!a%,i" (-iri.
(. P"a a5ti3ita -a Itira+at
K(,iaaaa itira+at %ai!9%ai! a!!ta 5("$ar!a Ny.TK
,(r,(-a ,(-a . Ny.TK %(%"i5i 5(,iaaa ti-$r ia! ,(!it$
$"a -(!a aa5ya ya! ,$!$. K(,iaaa ti-$r ia! 19)
8a%& %a"a% +ari ;9< 8a%. Ti-a5 a-a a!!ta 5("$ar!a %(!("$+
%(!a"a%i !a!!$a -a"a% +a" ti-$r.
6. K(,iaaa 5("$ar!a ya! %(r$!i5a 5((+ata
K("$ar!a ,$a! air ,(ar?,(ra5@ -i $!ai.
/2 Struktur Keluarga
1. P"a K%$i5ai K("$ar!a
K%$i5ai -a"a% 5("$ar!a ,(r8a"a -(!a ,ai5& ,i"a a-a
(r%aa"a+a -i%$yaara+5a.
). Str$5t$r K(5$ata K("$ar!a
K(r$5$a -a 5%$i5ai t(r,$5a 5+a $5$ 8aa %(r$a5a
5(5$ata a-a 5("$ar!a Ny.TK& %(r(5a %((ri%a 5(a-aa
%ai!9%ai! -a ,(rt(5a- %(8a!a 5(r$5$a 5("$ar!a.
*. Str$5t$r P(ra
;
8/17/2019 Askep Ibu Tukinadi
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S(tia a!!ta ,(r(ra ($ai iiya. Ny.TK ,(r(ra
(,a!ai 5(a"a 5("$ar!a -a aa59aa5 (,a!ai a!!ta 5("$ar!a
at$+ t(r+a-a i,$ya.
#2 ,ungsi Keluarga
S(2ara $%$% 5("$ar!a Ny. TK $-a+ %(%($+i 6$!i 5("$ar!a ,ai5
6$!i a6(5ti6 -a ia"iai -a 6$!i (raata 5((+ata.
82 Stres 5an Koping Keluarga
Ny.TK %(!ata5a ti-a5 %(raa a-aya tr( -a"a% 5("$ar!a
%(5i$ -ia %(ra!5a (,a!ai 5(a"a 5("$ar!a. Ny.TK $-a+
t(r,iaa 5ar(a $-a+ "a%a -iti!!a" $a%i.
92 ,aktor Lingkungan 5an Mas1arakat
1. R$%a+
K("$ar!a %((%ati r$%a+ (-iri& 8(i (%i (r%a(& -i-i!
t(%,5&"atai r$%a+ -i"(t(r& 3(ti"ai -a (2a+ayaa 2$5$
,ai5&((ra!a -(!a "itri5.
D(a+ R$%a+ K("$ar!a Ny.TK
* * * 7
1 U
) * 4
K(t(ra!a # # Pit$
1. T(ra R$%a+
). R$a! Ta%$
*. Ka%ar Ti-$r
4. Da$r
7. Ka%ar Ma-i
>
8/17/2019 Askep Ibu Tukinadi
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). Sa%a+
Sa%a+ r$%a+ ta!!a -i,$a! -ia%i! r$%a+ ,i"a ($+
-i,a5ar.
*. S$%,(r air %i$%
K("$ar!a %(!!$a5a $%$r !a"i ya! t(r"(ta5 -i,("a5a!
r$%a+& 5$a"ita air ,ai5& ti-a5 ,(r,a$ -a ti-a5 ,(raa.
4. Ja%,a K("$ar!a
K("$ar!a ti-a5 $ya 8a%,a (-iri & 5a"a$ ,$a! air ,(ar -i
$!ai.
7. P(%,$a!a Air Li%,a+
K("$ar!a Ny.TK ti-a5 %(%$yai a"$ra (%,$a!a air "i%,a+
;. Ha"a%a r$%a+
K("$ar!a ti-a5 %(%"i5i +a"a%a r$%a+& -i-(a r$%a+ a-a"a+
!a! 5-iiya ,(ri+..
>. Li!5$!a r$%a+
Li!5$!a -i(5itar r$%a+ ta%a5 5$ra! ,(ri+& t(ta!!a
%(%i"i5i 5a-a! t(ra5 ai ya! 5$ra! %(%($+i
5((+ata?-(5at (%$5i%a@.
8/17/2019 Askep Ibu Tukinadi
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II2 ANALISA DA*A
Data
Masalah
Keperawatan
Kemungkinan
'en1e6a6
*1pologi
Masalah
Data Su61ektif
1. K("$ar!a%(!ata5a Ny.TK (ra+ -iraat -i RS5ar(a %$ta,(r
). Ny.TK %(!ata5a5(a-aaya aat ii(+at -a ti-a5 a-a5("$+a
*. Ny.TK $-a+5tr" 5( RS (%(8a5
$"a! -iraat -ari RS.Data O61ektif
1. KU %ai+ "(%a+ t(%#*;&*C&Na-i 100: /%t&
TD 110/>00%%H!&RR #)0 :/%t BB 41 K!
). T$r!r 5$"it ,ai5& (rita"ti5 $$ r%a"M$a"?9@&5(%,$!?9@.
Pt(ia" (i!5atatat$ 5((+ata a-a Ny.TK
Ka-aa(8a+t(ra
Data Su61ektif
1.K("$ar!a %(!ata5a5a"a$ BAB -i$!ai
). Ny.TK %(%$yairiayat %$ta,(r Data O61ektif
1. K("$ar!a ti-a5 %(%i"5i 8a%,a -a SPAL
). Li!5$!a -i(5itar
r$%a+ 5tr& a-a5a-a! t(ra5 -(5atr$%a+
R(i5 t(r8a!5itya (ya5iti6(5i?Diar(@
K(ti-a5%a%$a5("$ar!a %(%("i+ara"i!5$!a 5ar(a
5$ra!ya (!(ta+$a 5("$ar!at(ta! K("i!
R(i5
III2 '&(&N3ANAAN
a2 Diagnose Keperawatan
1. Pt(ia" (i!5ata tat$ 5((+ata a-a Ny.TK 5("$ar!a Ny.TK
). R(i5 t(r8a-iya (ya5it i6(5i?-iar(@ ,(r+$,$!a -(!a
5(ti-a5%a%$a 5("$ar!a %(%("i+ara "i!5$!a 5ar(a 5$ra!ya
(!(ta+$a 5("$ar!a t(ta! K((+ata "i!5$!a.
'
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62 'erenanaan Keperawatan
No
D;
*u
Kriteria
&?aluasi
Stan5ar
&?aluasiInter?ensi
1 S(t("a+-i,(ri5a (raata("a%a 1
,$"a tat$5((+ata Ny.TK%(i!5at
S(t("a+-i"a5$5a 7 5a"i5$8$!a5("$ar!a -aat #
1. M(%a+a%it(ta! Diar(
). M(2(!a+t(r8a-iya
-iar( 5(%,a"i*. M(%a+a%i
2ara (a!!$"a!a Diar(.
(r,a"Pi5%tr
K("$ar!a%(!(rtit(ta! #
9 P(ya5it
-iar( 9 Daat
%(%,$atLGG
9 Da"a% 1 ,$"a ti-a5
%(-(rita-iar(
1.J("a5a -a -i5$i5a-(!aa 5("$ar!at(ta! (ya5it Diar( #
9 P(!(rtia
9 Ta-a -a !(8a"a -iar(9 P(y(,a, -iar(9 P(y(,ara 5$%a9 Cara (2(!a+a -a
(raata -iar().La5$5a -(%trai
(%,$ata LGG*.Pata$ 5(a-aa
5((+ata Ny.TK 4. Mti3ai/a8$r5a Ny.TK $t$5 ,(r,at/5tr" 5(
P$5(%a ,i"a a-a5("$+a.
) S(t("a+-i,(ri5a (raata("a%a 1
,$"a5("$ar!a-aat%(%("i+ara"i!5$!a(+i!!a
ti-a5 t(r8a-i (ya5iti6(5i ((rti-iar(
S(t("a+-i"a5$5a 7 5a"i5$8$!a5("$ar!a -aat
1.M(%a+a%it(ta!"i!5$!aya! (+at
).M(8a!a5(,(ri+a
"i!5$!a
(r,a"Pi5%tr
1.K("$ar!a-aat%(8("a5a t(ta!
"i!5$!a ,(ri+ -a(+at
).Li!5$!a r$%a+ ,(ri+
*.M(!$ra!i 5(,iaaaBAB -i$!ai
1.J("a5a -a -i5$i5at(ta! 5((+ata"i!5$!a #
9 Syarat r$%a+ ya!%(%($+i yarat5((+ata
9 P(ya5it a5i,at
"i!5$!a ya! 5$ra!(+at
9 P(2(!a+a t(r+a-a (ya5it a5i,at K("i!ya! ,$r$5
). Mti3ai 5("$ar!a $t$5
ti-a5 BAB -i $!ai
*. Mti3ai 5("$ar!a $t$5 5(r8a,a5ti -(!at(ta!!a -i(5itar r$%a+(tia 1 %i!!$ (5a"i
I@2 '&LAKSANAAN"IM'L&M&N*ASI
No2
D; +aktu
*in5akan
Keperawatan &?aluasi
10
8/17/2019 Askep Ibu Tukinadi
11/13
1 J$%at& '9079)00*
P5. 0'.*0 = 10.00
WIB
9 Ga"i (!(ta+$a
5("$ar!a t(ta!
(ya5it -iar(
9 Di5$i -(!a
5("$ar!a t(ta!
ti-a5a
5("$ar!a ya!
$-a+ -i"a5$5a
S # 9 K("$ar!a %(!ata5a ,a+a -iar(
a-a"a+ (ya5it ya! -ita-ai -(!a
,(ra5 t(r$ %((r$. K("$ar!a
%(!ata5a 5(%$!5ia -i(,a,5a
5ar(a a"a+ %a5a.
9 K("$ar!a ,("$% (%at %("a5$5a
(rt"!a -ir$%a+ 5ar(a Ny.TK
$-a+ -i,aa "a!$! 5( RS
O
A
P
#
#
#
- K("$ar!a %(raa ta5$t ,i"a
5(8a-ia -iar( t(r$"a! "a!i.
- K("$ar!a a%a5 t(rtari5
-(!a ,(,(raa %a$5a -ari
%a+aia
- K("$ar!a ,(r+ara -aat
-i8("a5a (2ara ri2i t(ta!
(ya5it -iar(.
- K$ra!ya (!(ta+$a
(-(rita t(ta! Diar(.P(y$"$+a t(ta! Diar(.
1 Ra,$&149079)00*
P5.0'.*0910.*0
WIB
M(%,(ri5a
(y$"$+a t(ta!
Diar( #
9 P(!(rtia
9 Ta-a -a !(8a"a-iar(
9 P(y(,a, -iar(9 P(y(,ara
5$%a9 Cara (2(!a+a
-a (raata-iar(
S
O
A
P
#
#
#
#
9 K("$ar!a %(!ata5a a+a%
-(!a (8("aa ya! -ia%ai5a
9 K("$ar!a -aat %(8("a5a 5(%,a"i
t(ta! P(!(rtia& ta-a -a !(8a"a
-iar(& P(y(,a, -iar(& P(y(,ara
5$%a -iar(& Cara (2(!a+a -a
(raata -iar(
P(!(ta+$a 5("$ar!a t(ta! -iar(
,(rta%,a+
D(%trai5a 2ara %(%,$at LGG
Pata$ 5(a-aa 5((+ata Ny.TK.
1 S("aa&)09079)00*
P5.0'.*0910.00
M(-(%trai
(%,$ata LGG
S # 9 K("$ar!a %(!ata5a a+a%
-(!a (8("aa ya! -ia%ai5a
11
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WIB O
A
P
#
#
#
9 K("$ar!a -aat %(-(%trai5a
(%,$ata LGG
P(!(ta+$a 5("$ar!a t(ta!
(%,$ata LGG ,(rta%,a+
Pata$ 5(a-aa 5((+ata Ny.TK.
) Ka%i&))9079)00*
P5.0'.*0910.00
WIB
M(%,(ri
(y$"$+a tt!
K((+ata
"i!5$!a
S
O
A
P
#
#
#
#
9 K("$ar!a %(!ata5a a+a%
-(!a (8("aa ya! -ia%ai5a
9 K("$ar!a -aat %(8("a5a 5(%,a"i
t(ta! r$%a+ ya! %(%($+i yarat
5((+ata
9 P(ya5it a5i,at "i!5$!a ya! 5$ra!
(+at
9 P(2(!a+a t(r+a-a (ya5it a5i,at
K("i! ya! ,$r$5
P(!(ta+$a 5("$ar!a t(ta!
5((+ata "i!5$!a
,(rta%a,a+?%aa"a+ ,("$% t(ratai@
9 Pata$ 5((+ata "i!5$!a
5("$ar!a
9 Mti3ai 5("$ar!a $t$5 5(r8a ,a5ti
9 Mti3ai 5("$ar!a $t$5 ti-a5 BAB
-i $!ai.
) S(i&);9079)00*
P5.0'.0090'.*0
WIB
M(%ata$
5((+ata
5("$ar!a -a
5((+ata
"i!5$!a
5("$ar!a
S
O
A
P
#
#
#
#
9 K("$ar!a %(!ta5a %ai+ BAB
-i$!ai 5ar(a ,("$% $ya WC
9 K("$ar!a ,(r8a8i $t$5 %(!+(ti5a
5(,iaaa BAB -i $!ai.
9 Ny.TK -a"a% 5(a-aa (+at a"a6iat
9 Li!5$!a -i(5itar r$%a+ ta%a5
"(,i+ ,(ri+ ?5("$ar!a 5(r8a ,a5ti
%(%,(ri+5a "i!5$!a )7/7/0*
Maa"a+ t(ratai (,a!ia
9 K(r8aa%a -(!a (t$!a $5(%a
,a! PHN $t$5 %(%ata$ 5((+ata
Ny.TK -a a!!ta 5("$ar!aya.
9 K(r8aa%a -(!a (rt$!a $5(%a
,a!.K("i! $t$5 ti-a5 "a8$t
1)
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(%,$ata 8a%,a 5("$ar!a.
9T(r%iai
1*