KELAS 2A Kelompok 2
KELAS 2A Kelompok 2 :
1. Ayu Dewi Vortuna
2. Dwi Rizky Maulana
3. Inda Wulandari
4. Imam Fahriz Pujiansyah
5. Jhon Kenedi
6. Novia Handayani
7. Putri Widiana
8. Rika Sri Winarsih
9. Lailatul Qadariah
10. Rival Akbar
11. Santo
12. Tuti Purwanti
Health care information exchange
Definition: providing patient care information to health professionals in other agencies
Activities: Identify referring nurse and location Identify essential demographic data Describe pertinent past healthhistory Identify current medical and nursing diagnoses Identify resolved nursing and medical diagnoses, as appropriate Describe nursing interventions beiag implemented Summarize progress of patient toward goals Describe medical treatment regimen, including diet, medications, and exercise Identify equipment and supplies necessary for care Identify anticipated discharge date Identify planned return appointment for follow-up care Describe role of family in continuing care Identify capabilities of patient and family in implementing care after discharge Identify other agencies providing care307 Kesehatan Pertukaran Informasi
Kesehatan Pertukaran Informasi 7960
DEFINISI: Memberikan informasi perawatan pasien untuk profesional kesehatan di instansi lain KEGIATAN: Mengidentifikasi rujukan perawat dan lokasi Mengidentifikasi data demografis yang penting Jelaskan riwayat kesehatan masa lalu yang bersangkutan Mengidentifikasi diagnosa medis dan keperawatan saat ini Mengidentifikasi keperawatan yang sudah diselesaikan dan diagnosa medis, yang sesuai Jelaskan intervensi keperawatan yang di laksanakan Meringkas kemajuan pasien menuju tujuan Jelaskan resimen pengobatan medis, termasuk diet, obat-obatan, dan olahraga Mengidentifikasi peralatan dan perlengkapan yang diperlukan untuk perawatan Mengidentifikasi tanggal debit diantisipasi Mengidentifikasi perencanaan janji pulang untuk perawatan tindak lanjut Jelaskan peran keluarga dalam perawatan berkelanjutan Mengidentifikasi kemampuan pasien dan keluarga dalam melaksanakan perawatan setelah debit Mengidentifikasi lembaga lain yang menyediakan perawatan
BACAAN LATAR BELAKANG: Kron,T.,&Gray,A. (1987). The management of patient care. Putting leadership skills to work
th (6 ed.). Philadephia: W.B Saunders. rd Little. D.E., & Carnevali, D.L. (1983). Nursing care planning (3 ed.). Philadelphia: J.B.
Lippincott.
seizure management definition: care of a patient during a seizure and the postictal state activities: guide movements to prevent injury monitor direction of head and eyes during seizure loosen clothing remain with patient during seizure maintain airway establish IV access, as appropriate apply oxygen, as appropriate monitor vital signs reorient after seizure
record seizure characteristics: body parts involved, motor activity and seizureprogression
document information about seizure administer medication, as appropriate administer anticonvulsants, as appropriate monitor antiepileptic drug levels, as appropriate monitor postical period duration and characteristics484 Manajemen Kejang
Manajemen Kejang 2680
DEFINISI: perawatan pasien selama kejang dan negara postictal KEGIATAN:
Panduan gerakan untuk mencegah cedera Memonitor arah kepala dan mata selama kejang Melonggarkan pakaian Tetap dengan pasien selama kejang Mempertahankan jalan napas Membangun akses IV, yang sesuai Berlaku oksigen, yang sesuai Memonitor tanda-tanda vital Reorientasi setelah kejang Mencatat karakteristik kejang: bagian tubuh yang terlibat, aktivitas motorik dan perkembangan kejang Mendokumentasikan informasi tentang kejang Mengelola obat, yang sesuai Mengelola antikonvulsan, yang sesuai Memonitor kadar obat antiepilepsi, yang sesuai Memonitor durasi periode postictal dan karakteristik BACAAN LATAR BELAKANG: Ackerman, L.L. (1992). Interventions related to neurological care. In G.M. Bulechek & J.C.
McCloskey (Eds.), Symposium on Nursing Interventions. Nursing Clinics of North America, 27(2), 325-346. Brewer, K., & Sperling. M.R. (1988). Neurosurgical treatment of intractable epilepsy.
Journal of Neuroscience Nursing, 20(6), 366-372.
Cammermeyer, M., & Appledorn, C. (1990). Core curriculurm for neuroscience nursing
rd (3 ed.) (pp. lgl-lg3. Chicago: American Association of Neuroscience Nurses.
Graham,O., Navea,I.,&Cummings,C. (1989).A model for ambulantory care of patients with epilepsy and other neurological disorders. Journal of Neuroscience Nursing, 21(2), 108- 112. Johanson,B.C., Wells,S.J., Hoffmeister,D.,&Dungca,C.U.(1988).Standards for critical
rd care (3 ed.). St. Louis: Mosby.
Santilli, N., & Sierzant, T.L. (1987). Advances in the treatment of epilepsy. Journal of Neurescience Nursing, 19(3), 141-155.
Wound care
Definition: prevention of wound complications and promotion of wound healing
Activities: Remove adhesive tape and debris Shave the hairsurrounding the affected are, as needed Note characteristics of the wound Note characteristics of any drainage Clean with antibacterial soap, as appropriate Place affected area in a whirlpool bath, as appropriate Soak in saline solution, as appropriate Administer IV site care, as appropriate Administer hickman line care, as appropriate Administer central venous line site care, as appropriate Provide incision site care, as needed Administer skin ulcer care, as needed Massage the area around the wound to stimulate circulationApply TENS (transcutaneous electrical nerve stimulation) unit for wound healing
enhancement, as appropriate Maintain patency of any drainage tubesApply an appropriate ointment to the skin / lesion, as appropriate Bandage appropriately
Apply an occlusive dressing, as appropriate Reinforce the dressing, as needed Dress with appropriate mes gauze, as needed Maintain sterile dressing technique when doing wound care Inspect the wound with each dressing change Compare and record regulary any changes in the wound
Position to avoid placing tension on the wound, as appropriate
Teach patient or family member(s) wound care procedures599 Perawatan Luka
Perawatan Luka 3660
DEFINISI: Pencegahan komplikasi luka dan promosi penyembuhan luka KEGIATAN: Lepaskan pita perekat dan puing-puing Mencukur rambut sekitar area yang terkena dampak, yang diperlukan Catatan karakteristik luka Catatan karakteristik drainase setiap Bersihkan dengan sabun antibakteri yang sesuai Tempatkan daerah yang terkena dalam pusaran air mandi, yang sesuai Rendam dalam larutan garam, yang sesuai Mengelola IV perawatan situs, yang sesuai Mengelola perawatan garis hickman, yang sesuai Mengelola garis perawatan situs vena sentral, yang sesuai Memberikan sayatan perawatan situs, yang diperlukan Mengelola perawatan ulkus kulit, yang diperlukan Pijat daerah sekitar luka untuk merangsang sirkulasi Terapkan TENS (stimulasi saraf transkutan listrik) Unit untuk luka peningkatan penyembuhan, yang sesuai Pertahankan kepatenan setiap tabung drainase Terapkan salep yang sesuai dengan kulit / lesi, yang sesuai perban Menerapkan ganti oklusif, yang sesuai
Memperkuat balutan yang diperlukan Meyediakan pakaian yang tipis jika diperlukan Mempertahankan teknik sterilisasi ketika melakukan perawatan luka Memeriksa luka dengan setiap pergantiaan balutan Bandingkan dan merekam regulary perubahan pada luka Posisikan untuk menghindari menempatkan ketegangan pada luka, yang sesuai Ajarkan anggota pasien atau keluarga untuk prosedur perawatan luka BACAAN LATAR BELAKANG: Cooper,D.M. (1990). Optimizing wound healing: A practice within nursing’s domain.
Nursing Clinics of North America, 25(1), 165-180 Garvin,G.(1990). Wound healing in pediatrics. Nursing Clinics of North America,25(1),181- 192.
Jones,PL.,&Millman,A. (1990). Wound healing and the aged patient. Nusing Clinics of America, 25(1), 263-278
rd
Kozier, B., & Erb , G (1989). Techniques in clinical nursing (3 ed). Menlo Park, CA: Addison-Wesley.
Perry,A.G., & Potter,P.A. (1990). Clinical nursing skills and techniques. St. Louis: Mosby. Risenberg, CS. (1990). Wound healing in the patient with diabetes mellitus. Nursing Clinics of North America, 25(1), 247-262.