tag:blogger.com,1999:blog-73804864186532783722024-03-12T17:19:54.825-07:00askep trauma capitisAnonymoushttp://www.blogger.com/profile/02763435950046267164noreply@blogger.comBlogger1125tag:blogger.com,1999:blog-7380486418653278372.post-72174141459771666572012-06-21T08:27:00.000-07:002012-06-21T08:27:51.527-07:00tugas ANTOK mahasiswa unanda<!--[if gte mso 9]><xml> <w:WordDocument> <w:View>Normal</w:View> <w:Zoom>0</w:Zoom> <w:TrackMoves/> <w:TrackFormatting/> <w:PunctuationKerning/> <w:ValidateAgainstSchemas/> <w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid> <w:IgnoreMixedContent>false</w:IgnoreMixedContent> <w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText> <w:DoNotPromoteQF/> <w:LidThemeOther>EN-US</w:LidThemeOther> <w:LidThemeAsian>X-NONE</w:LidThemeAsian> <w:LidThemeComplexScript>X-NONE</w:LidThemeComplexScript> <w:Compatibility> <w:BreakWrappedTables/> <w:SnapToGridInCell/> <w:WrapTextWithPunct/> <w:UseAsianBreakRules/> <w:DontGrowAutofit/> <w:SplitPgBreakAndParaMark/> <w:DontVertAlignCellWithSp/> <w:DontBreakConstrainedForcedTables/> <w:DontVertAlignInTxbx/> <w:Word11KerningPairs/> <w:CachedColBalance/> </w:Compatibility> <w:BrowserLevel>MicrosoftInternetExplorer4</w:BrowserLevel> <m:mathPr> <m:mathFont m:val="Cambria Math"/> <m:brkBin m:val="before"/> <m:brkBinSub m:val="--"/> <m:smallFrac m:val="off"/> <m:dispDef/> <m:lMargin m:val="0"/> <m:rMargin m:val="0"/> <m:defJc m:val="centerGroup"/> <m:wrapIndent m:val="1440"/> <m:intLim m:val="subSup"/> <m:naryLim m:val="undOvr"/> </m:mathPr></w:WordDocument> </xml><![endif]--><!--[if gte mso 9]><xml> <w:LatentStyles DefLockedState="false" DefUnhideWhenUsed="true"
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<div class="Section1"> <div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;"><b style="mso-bidi-font-weight: normal;">ASUHAN KEPERAWATAN PADA PASIEN CEDERA KEPALA</b></div><div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;"><b style="mso-bidi-font-weight: normal;">( TRAUMA CAPITIS )</b></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><ol start="1" style="margin-top: 0in;" type="A"><li class="MsoNormal" style="line-height: 150%; mso-list: l0 level1 lfo1; tab-stops: list .5in; text-align: justify;"><b style="mso-bidi-font-weight: normal;">KONSEP DASAR MEDIS</b></li>
</ol><div class="MsoNormal" style="line-height: 150%; margin-left: .75in; mso-list: l2 level1 lfo2; tab-stops: list .75in; text-align: justify; text-indent: -.25in;"><b style="mso-bidi-font-weight: normal;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></b><b style="mso-bidi-font-weight: normal;">DEFENISI</b></div><div class="MsoNormal" style="line-height: 150%; margin-left: .75in; text-align: justify;">Cedera kepala adalah suatu cedera yang menimbulkan kerusakan atau perlukaan pada kulit kepala, tulang tengkorak dan jaringan otak yang disertai perdarahan.</div><div class="MsoNormal" style="line-height: 150%; margin-left: .75in; text-align: justify;"><span lang="SV" style="mso-ansi-language: SV;">Cedera kepala dapat dibagi menurut berat dan ringan :</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: .75in; text-align: justify;"><i style="mso-bidi-font-style: normal;"><span lang="SV" style="mso-ansi-language: SV;">Cedera kepala Ringan :</span></i></div><div class="MsoNormal" style="line-height: 150%; margin-left: .75in; text-align: justify;"><span lang="SV" style="mso-ansi-language: SV;">Jika skala koma glasgow antara 14-15 dapat terjadi kehilangan kesadaran antara 30 menit tidak ada penyerta seperti fraktur tengkorak, kontusuo dan hematom, serta tidak terjadi gangguan neurologis.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: .75in; text-align: justify;"><i style="mso-bidi-font-style: normal;"><span lang="SV" style="mso-ansi-language: SV;">Cedera Kepala Sedang :</span></i></div><div class="MsoNormal" style="line-height: 150%; margin-left: .75in; text-align: justify;"><span lang="SV" style="mso-ansi-language: SV;">Jika skala koma glasgow antara 10-13, hilang kesadaran antara 30 menit – 24 jam dapat mengalami fraktur tengkorak, disorientasi ringan (bingung).</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: .75in; text-align: justify;"><i style="mso-bidi-font-style: normal;"><span lang="SV" style="mso-ansi-language: SV;">Cedera Kepala Berat :</span></i></div><div class="MsoNormal" style="line-height: 150%; margin-left: .75in; text-align: justify;"><span lang="SV" style="mso-ansi-language: SV;">Jika skala koma glasgow antara 3-8, hilang kesadaran lebih dari 24 jam meliputi contisio cerebral, lacerasi, hematom, dan edema cerebral.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: .75in; mso-list: l2 level1 lfo2; tab-stops: list .75in; text-align: justify; text-indent: -.25in;"><b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV;">ETIOLOGI</span></b></div><div class="MsoNormal" style="line-height: 150%; margin-left: .75in; text-align: justify;"><span lang="SV" style="mso-ansi-language: SV;">Hal yang menyebabkan cedera kepala adalah</span></div><ol start="2" style="margin-top: 0in;" type="1"><ol start="1" style="margin-top: 0in;" type="a"><li class="MsoNormal" style="line-height: 150%; mso-list: l2 level2 lfo2; tab-stops: list 1.0in; text-align: justify;"><span lang="FI" style="mso-ansi-language: FI;">Terjatuh dari ketinggian, benturan, dan pukulan</span></li>
<li class="MsoNormal" style="line-height: 150%; mso-list: l2 level2 lfo2; tab-stops: list 1.0in; text-align: justify;"><span lang="FI" style="mso-ansi-language: FI;">Kecelakaan kerja</span></li>
<li class="MsoNormal" style="line-height: 150%; mso-list: l2 level2 lfo2; tab-stops: list 1.0in; text-align: justify;"><span lang="FI" style="mso-ansi-language: FI;">Kecelakaan lallu lintas</span></li>
<li class="MsoNormal" style="line-height: 150%; mso-list: l2 level2 lfo2; tab-stops: list 1.0in; text-align: justify;"><span lang="FI" style="mso-ansi-language: FI;">Perkelahian, dll</span></li>
</ol></ol><div class="MsoNormal" style="line-height: 150%; margin-left: .75in; mso-list: l2 level1 lfo2; tab-stops: list .75in; text-align: justify; text-indent: -.25in;"><b style="mso-bidi-font-weight: normal;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="FI" style="mso-ansi-language: FI;">PATOFISIOLOGI</span></b></div><div class="MsoNormal" style="line-height: 150%; margin-left: .75in; text-align: justify; text-indent: .25in;"><span lang="FI" style="mso-ansi-language: FI;">Cedera kepala diakibatkan karena adnya benturan kuat yang mengakibatkan struktur intracranial (otak, darah, dan cairan serebrospinal) menjadi rusak sehingga sukar diabsorbsi oleh muskuloligamentum(yang menjaga kepala).Tulang tengkorak yang elastis pada anak-anak mengabsorbsi energi secara langsung dan mempengaruhi kepala dan memberikan proteksi pada struktur intracranial. Jaringan syaraf rentang tetapi biasanya untuk sampai terjadi kerusakan berarti harus ada tekanan yang kuat.Benturan kuat dapat diakibatkan pukulan langsung pada kepala maupun bagian tubuh lain dengan efek pantulan keotak atau luka secara tidak langsung. Respon otak terhadap benturan adalah berpindahny rongga kranial kedepan otak apat mementil atau berputar pada batang otak disebabkan oleh difusi pada luka pergerakan otak ini dapat menyebabkan luka memar atau luka robek akibat gerakan yang berlebihan pada permukaan kranial sebelah dalam frekuensi kerusakan terbesar terjadi pada tulang<span style="mso-spacerun: yes;"> </span>frontal dan lobus temporal otak.Lokasi /daerah kulit kepala banyak aliran darah pada anak dapat terjadi perdarahan yang menyebabkan kematian akibat adanya lacerasi yang hebatpada kulit kepala.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: .75in; mso-list: l2 level1 lfo2; tab-stops: list .75in; text-align: justify; text-indent: -.25in;"><b style="mso-bidi-font-weight: normal;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="FI" style="mso-ansi-language: FI;">MANIFESTASI KLINIS</span></b></div><div class="MsoNormal" style="line-height: 150%; margin-left: 1.0in; mso-list: l13 level1 lfo16; tab-stops: list 1.0in; text-align: justify; text-indent: -.25in;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">1)<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Cedera Kepala Ringan</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 99.0pt; mso-list: l2 level3 lfo2; mso-text-indent-alt: -.25in; tab-stops: list 63.0pt; text-align: justify; text-indent: -99.0pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;"><span style="font: 7.0pt "Times New Roman";"> </span>(a)<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Cedera kepala sekunder yang ditandai dengan nyeri kepala, tidak pingsang, tidak muntah, tidak ada tanda – tanda neurologik</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 99.0pt; tab-stops: list 81.0pt; text-align: justify; text-indent: -27.0pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-spacerun: yes;"> </span>(b) <span style="mso-tab-count: 1;"> </span>Contusio serbri ditandai dengan tidak sadar <span style="mso-spacerun: yes;"> </span>krang dari<span style="mso-spacerun: yes;"> </span>10 menit, muntah, sakit kepala, tidak ada tanda – tanda nerologik kontisio cerebri</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 1.0in; mso-list: l13 level1 lfo16; tab-stops: list 1.0in; text-align: justify; text-indent: -.25in;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">2)<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Cedera Kepala Sedang</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 1.0in; text-align: justify;"><span lang="SV" style="mso-ansi-language: SV;">Ditandai dengan pingsan ≥ 10 menit muntah dan anamnesa retrogard</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 1.0in; tab-stops: 328.5pt; text-align: justify;"><span lang="SV" style="mso-ansi-language: SV;">dan tanda – tanda neurologik<span style="mso-tab-count: 1;"> </span></span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 63.0pt; mso-list: l13 level1 lfo16; tab-stops: list 63.0pt; text-align: justify; text-indent: -9.0pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">3)<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Cedra Kepala Berat </span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 1.25in; mso-list: l16 level1 lfo3; tab-stops: list 1.25in; text-align: justify; text-indent: -.25in;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">a)<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Lacerasi cerebri ditandai dengan pingsan berhari-hari atau berbulan-bulan,kelumpuhan anggota gerak biasanya disertai fraktur basis cranii.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 1.25in; mso-list: l16 level1 lfo3; tab-stops: list 1.25in; text-align: justify; text-indent: -.25in;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">b)<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Perdarahan epidural ditandai dengan pingsan sebentar-bentarkemudian sadar lagi kemudian pingsan lagi, mata sembab, pupil anisokor bradikardi, tekanan darah menurun, suhu tubuh meningkat.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 1.25in; mso-list: l16 level1 lfo3; tab-stops: list 1.25in; text-align: justify; text-indent: -.25in;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">c)<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Perdarahan subdural ditandai dengan nyeri kepala intrakranial meningkat dan lumpuh.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: .75in; mso-list: l2 level1 lfo2; tab-stops: list .75in; text-align: justify; text-indent: -.25in;"><b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV;">PEMERIKSAAN PENUNJANG</span></b></div><ol start="1" style="margin-top: 0in;" type="A"><ol start="1" style="margin-top: 0in;" type="a"><li class="MsoNormal" style="line-height: 150%; mso-list: l0 level2 lfo1; tab-stops: list 1.0in; text-align: justify;"><span lang="SV" style="mso-ansi-language: SV;">Tes Diagnostik</span></li>
</ol></ol><div class="MsoNormal" style="line-height: 150%; margin-left: 1.25in; mso-list: l14 level3 lfo18; tab-stops: list 1.25in; text-align: justify; text-indent: -.25in;"><span lang="SV" style="font-family: SimSun; mso-ansi-language: SV; mso-bidi-font-family: SimSun;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">CT-Scan Kepal</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 1.25in; mso-list: l14 level3 lfo18; tab-stops: list 1.25in; text-align: justify; text-indent: -.25in;"><span lang="SV" style="font-family: SimSun; mso-ansi-language: SV; mso-bidi-font-family: SimSun;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Foto Rontgen /<span style="mso-spacerun: yes;"> </span>Foto Kepala : untuk mengetahui perubahan struktur tengkorak</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 1.0in; text-align: justify; text-indent: -.25in;"><span lang="SV" style="mso-ansi-language: SV;">b.<span style="mso-spacerun: yes;"> </span><span style="mso-tab-count: 1;"> </span>Laboratorium </span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 1.0in; text-align: justify;"><span lang="SV" style="mso-ansi-language: SV;">Leukosit, Pemeriksaan Darah Lengkap, Analisa Gas Darah, Hb, Elektrolit. <span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span></span></div></div><span lang="SV" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: SV; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;"><br clear="all" style="mso-break-type: section-break; page-break-before: always;" /> </span> <div class="MsoNormal" style="line-height: 150%; margin-left: .25in; mso-list: l0 level1 lfo1; tab-stops: list .25in left 110.25pt; text-align: justify; text-indent: -.25in;"><b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">B.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="SV" style="mso-ansi-language: SV;">KONSEP KEPERAWATAN<span style="mso-tab-count: 1;"> </span></span></b></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: medium none; margin-left: -0.8in; width: 1140px;"><tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;"> <td style="border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: .5in;" width="48"> <div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><span lang="SV" style="mso-ansi-language: SV;">NO</span></div></td> <td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 2.0in;" width="192"> <div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><span lang="SV" style="mso-ansi-language: SV;">DATA</span></div></td> <td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 117.0pt;" width="156"> <div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><span lang="SV" style="mso-ansi-language: SV;">DIAGNOSA KEPRAWATAN</span></div></td> <td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 1.75in;" width="168"> <div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><span lang="SV" style="mso-ansi-language: SV;">TUJUAN</span></div></td> <td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 2.5in;" width="240"> <div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><span lang="SV" style="mso-ansi-language: SV;">RENCANA KEPERAWATAN</span></div></td> <td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 3.5in;" width="336"> <div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><span lang="SV" style="mso-ansi-language: SV;">RASIONAL</span></div></td> </tr>
<tr style="height: 233.3pt; mso-yfti-irow: 1; mso-yfti-lastrow: yes;"> <td style="border-top: none; border: solid windowtext 1.0pt; height: 233.3pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: .5in;" width="48"> <div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><span lang="SV" style="mso-ansi-language: SV;">1.</span></div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
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</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><span lang="SV" style="mso-ansi-language: SV;">2.</span></div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
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</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><span lang="SV" style="mso-ansi-language: SV;">3.</span></div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
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</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><span lang="SV" style="mso-ansi-language: SV;">4.</span></div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
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</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><span lang="SV" style="mso-ansi-language: SV;">5.</span></div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><span lang="SV" style="mso-ansi-language: SV;">6.</span></div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><br />
</div><div align="center" class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: center;"><span lang="SV" style="mso-ansi-language: SV;">7.</span></div></td> <td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 233.3pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 2.0in;" valign="top" width="192"> <div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><span lang="SV" style="mso-ansi-language: SV;">DS : </span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l5 level1 lfo17; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Klien mengatakan bengakak pada bagian kepala.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l5 level1 lfo17; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Klien mengatakan nyeri/pusing di daerah kepala</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><span lang="SV" style="mso-ansi-language: SV;">DO</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l5 level1 lfo17; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Ekspresi wajah meringis</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l5 level1 lfo17; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">KU lemah</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .25in; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><span lang="SV" style="mso-ansi-language: SV;">DS :</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l5 level1 lfo17; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Klien mengatakan nyeri<span style="mso-spacerun: yes;"> </span>di daerah kepala</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><span lang="SV" style="mso-ansi-language: SV;">DO</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l5 level1 lfo17; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Ekspresi wajah meringis</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><span lang="SV" style="mso-ansi-language: SV;">DS :</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l5 level1 lfo17; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Klien mengeluh sesak</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l5 level1 lfo17; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Klien mengeluh batuk berlendir</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><span lang="SV" style="mso-ansi-language: SV;">DO :</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l5 level1 lfo17; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Klien nampak sesak</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l5 level1 lfo17; tab-stops: list 12.6pt left 110.25pt; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Klien nampak menggunakan bantuan pernapasan</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l5 level1 lfo17; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Klien nampak batuk berdahak.</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><span lang="SV" style="mso-ansi-language: SV;">DS :</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l5 level1 lfo17; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Klien mengeluh malas makan</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l5 level1 lfo17; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Klien mengeluh mual dan muntah</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><span lang="SV" style="mso-ansi-language: SV;">DO :</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l5 level1 lfo17; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">KU lemah</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l5 level1 lfo17; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Porsi makan tidak di habiskan</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><span lang="SV" style="mso-ansi-language: SV;">DS : </span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l5 level1 lfo17; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Klien mengeluh tidak dapat menggerakkan bagian tubuhnya</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l5 level1 lfo17; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Klien mengatakan aktivitas di bantu oleh keluarga dan perawat</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><span lang="SV" style="mso-ansi-language: SV;">DO</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l5 level1 lfo17; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">KU lemah</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l5 level1 lfo17; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Klien nampak bedrest total</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l5 level1 lfo17; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Aktivitas di bantu oleh keluarga dan perawat</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><span lang="SV" style="mso-ansi-language: SV;">DS :</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l5 level1 lfo17; tab-stops: list 12.6pt left 110.25pt; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Klien mengatakan tampak kemerahan pada bagian luka</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l5 level1 lfo17; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Klien mengatakan badannya panas</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><span lang="FI" style="mso-ansi-language: FI;">DO :</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l5 level1 lfo17; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Ku lemah</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l5 level1 lfo17; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Tampak kemerahan pada bagian luka.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l5 level1 lfo17; tab-stops: list 12.6pt; text-align: justify; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">S : 38<sup>0</sup>C</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span lang="FI" style="mso-ansi-language: FI;">DS :</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l5 level1 lfo17; tab-stops: list 12.6pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Klien mengatakan bingung dimana dia sekarang berada</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l5 level1 lfo17; tab-stops: list 12.6pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Klien mengatakan tidak merespon tentang apa yang dikatkan orang sekitarnya.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span lang="SV" style="mso-ansi-language: SV;">DO :</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l5 level1 lfo17; tab-stops: list 12.6pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Klien tampak sering mengalihkan perhatiannya.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l5 level1 lfo17; tab-stops: list 12.6pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Terjadi disorientasi wktu,tempat,orang dan lingkungan pada klien.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l5 level1 lfo17; tab-stops: list 12.6pt; text-align: justify; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Terjadi perubahan kepribadian pada klien.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: .25in; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .25in; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .25in; tab-stops: 110.25pt; text-align: justify;"><br />
</div></td> <td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 233.3pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 117.0pt;" valign="top" width="156"> <div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><span lang="SV" style="mso-ansi-language: SV;">Perubahan Perubahn Perfusi Jaringan Otak b/d Adanya edema otak, hematom dan perdarahan </span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
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</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
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</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><span lang="FI" style="mso-ansi-language: FI;">Gangguan rasa nyaman nyeri kepala b/d kerusakan jaringan otak dan perdarahan serta meningkatnya tekanan intrakranial </span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt;"><span lang="SV" style="mso-ansi-language: SV;">Ketidak efektifan jalan nafas b/d kerusakan neurovaskuler cedera pada pusat pernapasan otak.</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%;"><span lang="SV" style="mso-ansi-language: SV;">Perubahan nutrisi kurang dari kebutuhan tubuh b/d perubahan kemampuan untuk mencerna makanan akibat penurunan tingkat kesadaran.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><span lang="FI" style="mso-ansi-language: FI;">Keterbatasan mobilitas fisik b/d kelemahan dan penurunan kekuatan otot tubuh</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt;"><span lang="SV" style="mso-ansi-language: SV;">Resiko infeksi b/d trauma jaringan ruasknya kulit dan prosedur invasi </span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><span lang="SV" style="mso-ansi-language: SV;">Perubahan proses pikir b/d perubahan fisiologis / konflik psikologis.</span></div></td> <td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 233.3pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 1.75in;" valign="top" width="168"> <div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><span lang="SV" style="mso-ansi-language: SV;">Tidak terjadi perfusi jaringan serbral dan TTV dalam batas normal</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
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</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
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</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
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</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
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</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><span lang="SV" style="mso-ansi-language: SV;">Kebuthan rasa nyaman<span style="mso-spacerun: yes;"> </span>terpenuhi.</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
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</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
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</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
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</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
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</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><span lang="SV" style="mso-ansi-language: SV;">Mempertahankan pola napas normal dan efektif.</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
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</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><span lang="SV" style="mso-ansi-language: SV;">Kebutuhan nutrisi terpenuhi dan BB tetap dan tidak mengalami penurunan.</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
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</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><span lang="SV" style="mso-ansi-language: SV;">Pasien dapat melakukan aktivitas fisik secara bertahap dan tidak terjadi kontraktur</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
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</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
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</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt;"><span lang="SV" style="mso-ansi-language: SV;">Tidak terjadi tanda-tanda infeksi, kemerahan, bengkak, dan peningkatan suhu tubuh.</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
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</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><span lang="SV" style="mso-ansi-language: SV;">Mempertahankan kembali orientasi mental dan orientasi biasanya<span style="mso-spacerun: yes;"> </span>dan berpartisipasi dalam aturan terapeutik.</span></div></td> <td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 233.3pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 2.5in;" valign="top" width="240"> <div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l8 level1 lfo9; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Kaji status neurologik secara teratur, respon membuka mata, dan respon motorik serta bandingkan dengan nilai standar.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l8 level1 lfo9; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Monitor TTV tiap setengah sampai satu jam.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l8 level1 lfo9; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Evaluasi ukuran pupil, raspon mata terhadap cahaya, pergerakan bola mata dan refleks kornea.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l8 level1 lfo9; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Atur posisi kepala dan mengangkat kepala tempat tidur sesuai indikasi.</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: list 12.6pt left 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l8 level1 lfo9; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Evaluasi keadaan pupil catat ukuran, ketajaman, kesimetrisan dan reaksi terhadap cahaya.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l8 level1 lfo9; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Penatalaksanaan pemberian </span></div><div class="MsoNormal" style="line-height: 150%; margin-left: .5in; mso-list: l9 level1 lfo4; tab-stops: list .5in left 110.25pt; text-align: justify; text-indent: -.25in;"><span lang="FI" style="font-family: Wingdings; mso-ansi-language: FI; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">Ø<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Obat sesuai indikasi, cairan, & pemberian oksigen tambahan</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: .5in; mso-list: l9 level1 lfo4; tab-stops: list .5in left 110.25pt; text-align: justify; text-indent: -.25in;"><span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">Ø<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Pemeriksaan radiologi</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: .5in; mso-list: l9 level1 lfo4; tab-stops: list .5in left 110.25pt; text-align: justify; text-indent: -.25in;"><span lang="SV" style="font-family: Wingdings; mso-ansi-language: SV; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">Ø<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Rujuk ke perawatan yang lebih intensif</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: .5in; mso-list: l9 level1 lfo4; tab-stops: list .5in left 110.25pt; text-indent: -.25in;"><span lang="FI" style="font-family: Wingdings; mso-ansi-language: FI; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">Ø<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Persiapan untuk pembedahan jika di perlukan.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: .25in; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .25in; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .25in; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .25in; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .25in; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .25in; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: 20.1pt; mso-list: l7 level1 lfo6; tab-stops: list 20.1pt left 110.25pt; text-align: justify; text-indent: -16.5pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Kaji lokasi nyeri dan intesitasnya.</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: 20.1pt; mso-list: l7 level1 lfo6; tab-stops: list 20.1pt left 110.25pt; text-align: justify; text-indent: -16.5pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Kaji TTV</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 20.1pt; mso-list: l7 level1 lfo6; tab-stops: list 20.1pt left 110.25pt; text-align: justify; text-indent: -16.5pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Ajarkan relaksasi serta napas dalam.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 20.1pt; mso-list: l7 level1 lfo6; tab-stops: list 20.1pt left 110.25pt; text-align: justify; text-indent: -16.5pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Berikan posisi tidur datar tanpa bantal.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 20.1pt; mso-list: l7 level1 lfo6; tab-stops: list 20.1pt left 110.25pt; text-align: justify; text-indent: -16.5pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Kolaborasi dengan dokter untuk pembaerian analgetik.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: -5.4pt; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: -5.4pt; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .05in; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .05in; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .05in; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .05in; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .05in; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .05in; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .05in; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l9 level2 lfo4; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Kaji frekuensi irama kedalaman pernapasan untuk mengetahui perlunya ventilasi mekanis.</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l9 level2 lfo4; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Auskultasi suara napas, perhatikan hipoventilasi dan adanya suara napas tambahan yang tidak normal.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l9 level2 lfo4; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Lakukan pengisapan lendir (suction) ekstra hati-hati 10-15 <span style="mso-spacerun: yes;"> </span>detik dan mencatat karakter warna dan kekeruhan dari secret</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l9 level2 lfo4; tab-stops: list 12.6pt left 110.25pt; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Kolaborasi : pemeriksaan radiologi ulang, analisa gas darah, fisioterapi dada jika ada indikasi.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: .3in; tab-stops: 110.25pt; text-align: justify; text-indent: -.25in;"><span lang="FI" style="mso-ansi-language: FI;">1. Kaji kemampuan pasien untuk menelan dan mengunyah batuk dan mengatasi sekresi.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: .3in; tab-stops: 110.25pt; text-align: justify; text-indent: -.25in;"><span lang="FI" style="mso-ansi-language: FI;">2. Auskultasi bising usus, cepat, adanya penurunan suara yang hiperaktif.</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .3in; tab-stops: 110.25pt; text-align: justify; text-indent: -.25in;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .3in; tab-stops: 110.25pt; text-align: justify; text-indent: -.25in;"><span lang="SV" style="mso-ansi-language: SV;">3. Timbang BB tiap hari atau sesuai dengan indikasi.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: .05in; tab-stops: 110.25pt; text-align: justify;"><span lang="SV" style="mso-ansi-language: SV;">4.<span style="mso-spacerun: yes;"> </span>Kolaborasi dengan ahli diet.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: .05in; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .05in; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .05in; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .3in; mso-list: l9 level2 lfo4; tab-stops: list .3in left 110.25pt; text-align: justify; text-indent: -.25in;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Kolaborasi dengan dokter tentang prosedur respon yang lain ubtuk intake nutrisi.</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; tab-stops: 110.25pt; text-align: justify; text-indent: -12.6pt;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l12 level1 lfo5; tab-stops: list 12.6pt left 110.25pt; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Kaji kemampuan fisik untuk untuk mengidentifikasi kekuatan otot / kelemahan anggota gerak.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l12 level1 lfo5; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Kaji tingkat kemampuan mobilis</span><span lang="FI" style="mso-ansi-language: FI;">asi.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l12 level1 lfo5; tab-stops: list 12.6pt left 110.25pt; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Bantu pasien melakukan latihan gerak aktif atau pasif pada semua ekstremitas untuk meminimalkan atrofi otot , meningkatkan sirkulasi membantu mencegah kontraktur.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l12 level1 lfo5; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -.25in;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Atur posisi pasien setiap 2 jam untuk mengurangi penekanan pada bagian tubuh tertentu.</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l12 level1 lfo5; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -.25in;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Memberikan perawatan kulit, massage dan menjaga agar alat tenun tetap kering dan bersih.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: -5.4pt; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l12 level1 lfo5; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -.25in;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Kolaborasi dengan dokter fisioterapi dan pemberian obat relaksan otot dan anti spasmodik sesuai indikasi.</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .25in; mso-list: l17 level1 lfo7; tab-stops: list .25in left 110.25pt; text-align: justify; text-indent: -.25in;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Observasi TTV setiap 1-2 jam </span></div><div class="MsoNormal" style="line-height: 150%; margin-left: .25in; mso-list: l17 level1 lfo7; tab-stops: list .25in left 110.25pt; text-align: justify; text-indent: -.25in;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Cuci tangan sebelum dan sesudah kontak dengan pasien.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: .25in; mso-list: l17 level1 lfo7; tab-stops: list .25in left 110.25pt; text-align: justify; text-indent: -.25in;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Observasi daerah kulit yang mengalami kerusakan (spt : luka, bekas jahitan) daerah yang terpasang alat invasi(spt : infus) catat adanya inflamasi.</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .25in; mso-list: l17 level1 lfo7; tab-stops: list .25in left 110.25pt; text-align: justify; text-indent: -.25in;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Kolaborasi dengan dokter untuk pemberian antibiotik dan pemeriksaan laboratorium leukosit.</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .25in; mso-list: l15 level1 lfo8; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -.25in;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Kaji rentng perhatian, kebingungan dan dan ansietas (kecemasan) pasien</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .25in; mso-list: l15 level1 lfo8; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -.25in;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-spacerun: yes;"> </span>Beri penjelasan mengenai prosrdur-prosedur dan tekankan kembali penjelasan yang diberikan oleh sejawat lain beri informasi tentang proses penyakit yang ada hubungannya dengan gejala yang muncul.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: .25in; mso-list: l15 level1 lfo8; tab-stops: list 12.6pt left 110.25pt; text-indent: -.25in;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-spacerun: yes;"> </span>Terapkan komunikasi terapeutik / lingkungan terapeutik.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: .25in; mso-list: l15 level1 lfo8; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -.25in;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-spacerun: yes;"> </span>Hindari meninggalkan pasien sendrian ketika mengalami agitasi, gelisa, atau berontak.</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .25in; mso-list: l15 level1 lfo8; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -.25in;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-spacerun: yes;"> </span>Kolaborasi dangan dokter tentang program rehabilitasi sesuai indikasi. </span></div></td> <td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 233.3pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 3.5in;" valign="top" width="336"> <div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l15 level2 lfo8; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Mengkaji adanya kecenderungan pada tingkat kesadaran dan potensial peningkatan tekanan intrakranial dan bermanfaat dalam menentukan loksi perluasan dan perkembangan kerusakan sistem sysraf pusat dan menentukan tingkat kesadaran.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l15 level2 lfo8; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Untuk mengetahui intervensi selanjutnya.</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l15 level2 lfo8; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Reaksi pupil diatur oleh syaraf kranial okulamotor III dan berguna untuk apakah batang otak masih baik.</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l15 level2 lfo8; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Kepala yang miring pada salah satu sisi menekan vena jugularis dan menghambat aliran darah ke vena yang selanjutnya akan meningkatkan TIK.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l15 level2 lfo8; tab-stops: list 12.6pt left 110.25pt; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Reaksi pupil diatur oleh kranialokulomotor III dan berguna untuk menentukan apakah batang otak masih baik.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: .3in; mso-list: l15 level2 lfo8; tab-stops: list 12.6pt left 110.25pt; text-indent: -.3in;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">- untuk memaksimalkan O<sub>2</sub> pada daerah arteri dan membantu pencegahan hipoksia</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: .3in; text-indent: -9.0pt;"><span lang="SV" style="mso-ansi-language: SV;">- untuk melihat kembali tanda-tanda komplikasi yang berkembang ( spt : atelektasis / bronkopnemonia ).</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: .3in; tab-stops: 110.25pt; text-align: justify; text-indent: -9.0pt;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .3in; tab-stops: 110.25pt; text-align: justify; text-indent: -9.0pt;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .3in; tab-stops: 110.25pt; text-align: justify; text-indent: -9.0pt;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .3in; tab-stops: 110.25pt; text-align: justify; text-indent: -9.0pt;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .3in; tab-stops: 110.25pt; text-align: justify; text-indent: -9.0pt;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .3in; tab-stops: 110.25pt; text-align: justify; text-indent: -9.0pt;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .3in; tab-stops: 110.25pt; text-align: justify; text-indent: -9.0pt;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .3in; tab-stops: 110.25pt; text-align: justify; text-indent: -9.0pt;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .3in; tab-stops: 110.25pt; text-align: justify; text-indent: -9.0pt;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .3in; tab-stops: 110.25pt; text-align: justify; text-indent: -9.0pt;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: .3in; tab-stops: 110.25pt; text-align: justify; text-indent: -9.0pt;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l1 level1 lfo13; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="SV" style="mso-ansi-language: SV;">Untuk memilih intervensi yang cocok dan untuk mengivakuasi keefektifan dari terapi yang di berikan.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l1 level1 lfo13; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Memudahkan intervensi selanjutnya.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l1 level1 lfo13; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Diharapkan dapat terjadi relaksasi pada otot-otot sehingga suplay O<sub>2 </sub>kejaringan terpenuhi </span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l1 level1 lfo13; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Mencegah terjadinya TIK</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l1 level1 lfo13; tab-stops: list 12.6pt; text-align: justify; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Analgetik berfungsi memblok reseptor nyeri sehingga nyeri tidak dipersepsikan secara berlebihan.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l6 level1 lfo10; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Perubahan menandakan awitan komplikasi pulmonal (umumnya mengikuti cedera otak) atau menandakan lokasi atau luasnya keterlibatan otak.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l6 level1 lfo10; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Untuk mengetahui adanya infeksi paru.</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l6 level1 lfo10; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Pengisapan biasanya dilakukan jika pasien<span style="mso-spacerun: yes;"> </span>koma atau immobilisasi dan tidak dapat membersihkan jalan napasnya sendiri. Penghisapan pada trakea lebih dalam harus dilakukan ekstra hati-hati karena dapat menyebabkan/meningkatkan hipoksia yang menimbulakan vasokontriksi akan berpengaruh cukup besar pada perfusi serebral.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l6 level1 lfo10; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Untuk mengidentifikasi adanya masalah paru seperti atelektasis, kongesti atau obstruksi jalan napas yang membahayakan oksigenasi serebral atau menandakan terjadinya infeksi paru </span></div><div class="MsoNormal" style="line-height: 150%; margin-left: .3in; mso-list: l10 level1 lfo11; text-align: justify; text-indent: -.25in;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Untuk memudahkan pemilihan terhadap jenis makanan sehingga pasien terlindung dari aspirasi.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: .3in; mso-list: l10 level1 lfo11; text-align: justify; text-indent: -.25in;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Fungsi saluran pencernaan biasanya tetap baikpada kasus cedera kepala jadi bising usus membantu dan menentukan respon untuk makan atau berkembangnya komplikasi seperti paralitik ileus.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: .3in; mso-list: l10 level1 lfo11; text-align: justify; text-indent: -.25in;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Mengevakuasi keefentifan atau kebutuhan mengubah pemberian nutrisi.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: .3in; mso-list: l10 level1 lfo11; text-align: justify; text-indent: -.25in;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Merupakan sumber yang efektif untuk mengidentifikasi kebutuhan nalori\nutrisi tergantung pada usia, BB, ukuran tubuh, keadaan penyakit sekarang (trauma, penyakit jantung/masalah metabolisme.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: .3in; mso-list: l10 level1 lfo11; text-align: justify; text-indent: -.25in;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Makanan melalui selang mungkin di perlukan pada awal pemberian jika pasien mampu menelan makanan lunak atau setengah cair mungkin lebih mudah di berikan tanpa menimbulkan aspirasi.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l11 level1 lfo12; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Mengidentifikasi kemungkinan kerusakan secara fungsional dan mempengaruhi pilihan intervensi yang akan di lakukan.</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l11 level1 lfo12; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Memudahkan intevensi selanjutnya.</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l11 level1 lfo12; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Mempertahankan mobilitas dan fungsi sendi/posisi norman extremitas dan menurunkan terjadinya vena yang statis.</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l11 level1 lfo12; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Perubahan posisi yang teratur menyebabkan penyeburan terhadap berat badan dan meningkatkan serkulasi pada seluruh tubuh jika ada harus di ubah posisinya secara teratur dan posisi dari daerah yang sakit hanya dalam jangka waktu yang sangat terbatas.</span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l11 level1 lfo12; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Meningkatkan serkulasi dan elastisitas kulit dan menurunkan resiko terjadinya </span></div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; tab-stops: 110.25pt; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l11 level1 lfo12; tab-stops: list 12.6pt left 110.25pt; text-align: justify; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Menyeimbangkan tekanan jaringan meningkatkan serkulasi dan membantu meningkatkan arus balik vena untuk menurunkan resiko terjadinya trauma jaringan.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l3 level1 lfo14; tab-stops: list 12.6pt; text-align: justify; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Memudahkan intervensi selanjutnya.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l3 level1 lfo14; tab-stops: list 12.6pt; text-align: justify; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Merupakan cara pertama untuk menghindari terjadinya infeksi nosokomial.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l3 level1 lfo14; tab-stops: list 12.6pt; text-align: justify; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Deteksi dini perkembangan infeksi memungkinkan untuk melakukan tindakan dengan segera dan pencegahan terhadap komplikasi selanjutnya.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l3 level1 lfo14; tab-stops: list 12.6pt; text-align: justify; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Terapi profilaktif di gunakan pada pasien yang mengalami trauma(perlukaan) atau setelah di lakukan pembedahan untuk menurunkan resiko terjadinya infeksi nosokomial.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l4 level1 lfo15; tab-stops: list 12.6pt; text-align: justify; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Rentang perhatian / keterampilan untuk berkonsetrasi mungkin mungkin memendek secara tajam yang menyebabkan dan merupakan potensi terhadap terjadinya ansietas yang mempengaruhi proses pikir pasien.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l4 level1 lfo15; tab-stops: list 12.6pt; text-align: justify; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Kehilangan struktur internal (perubahan dalam memori, alasan dan kemampuan untuk membuat konseptual) menimbulkan ketakutan baik terhadap pengaruh proses yang tidak diketahui maupun referensi terhadap informasi.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l4 level1 lfo15; tab-stops: list 12.6pt; text-align: justify; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Menurunkan frustasi yang berhubungan dengan perubahan kemampuan / pola respon yang memanjang.</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l4 level1 lfo15; tab-stops: list 12.6pt; text-align: justify; text-indent: -12.6pt;"><span lang="SV" style="mso-ansi-language: SV;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Ansietas dapat mengakibatkan kehilangan kontrol dan meningkatkan kepanikan. </span><span lang="SV" style="mso-ansi-language: SV;">Dukungan dapat memberikan keterangan yang menurunkan ansietas dan resiko terjadinya trauma</span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.6pt; mso-list: l4 level1 lfo15; tab-stops: list 12.6pt; text-indent: -12.6pt;"><span lang="FI" style="mso-ansi-language: FI;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="FI" style="mso-ansi-language: FI;">Untuk mengatasi masalah, konsentrasi, memori, daya penilaian dan penyelesaian masalah.</span></div></td> </tr>
</tbody></table><div class="MsoNormal"><br />
</div>Anonymoushttp://www.blogger.com/profile/02763435950046267164noreply@blogger.com0