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Asuhan Keperawatan Pasien Illeus Obstruksi

PENGKAJIAN
  1. Identitas klien

  2. Aktifitas / istirahat
    Lemah, gelisah
  3. Sirkulasi
    Takikardia, berkeringat
  4. Eliminasi
    Perubahan warna urine dan feces, distensi abdomen
  5. Makanan / cairan
    Mual / muntah, nyeri epigastrium
  6. Nyeri / kenyamanan
    Adanya insisi pembedahan
  7. Pernafasan
    Peningkatan frekuensi pernafasan, pernafasan tertekan ditandai oleh nafas pendek, dangkal
  8. Laboratorium
    Antara lain : Hb/Ht, leukosit, trombisit, elektrolit, AGD


DIAGNOSA KEPERAWATAN
  1. Pola nafas tidak efektif

  2. Resiko tinggi kekurangan volume cairan

  3. Gangguan integritas kulit
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