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Asuhan Keperawatan Pasien Sifilis

Pengkajian
  1. Pemeriksaan fisik
    • Keadaan umum

    • Kesadaran, status gizi, TB, BB, suhu, TD, nadi, respirasi

  2. Pemeriksaan sistemik

    Kepala (mata, hidung, telinga, gigi & mulut), leher (terdapat perbesaran tyroid atau tidak), tengkuk, dada (inspeksi, palpasi, perkusi, auskultasi), genitalia, ekstremitas atas dan bawah.


  3. Pemeriksaan penunjang
    Pemeriksaan laboratorium (kimia darah, ureum, kreatinin, GDS, analisa urin, darah rutin)


Diagnosa Keperawatan yang Muncul
  1. Nyeri kronis b.d adanya lesi pada jaringan

  2. Hipertermi b.d proses infeksi

  3. Cemas b.d proses penyakit


Diagnosa Keperawatan 1. :
Nyeri kronis b.d adanya lesi pada jaringan

Tujuan :
Nyeri klien hilang dan kenyamanan terpenuhi

Kriteria Hasil :
  • Nyeri klien berkurang
  • Ekspresi wajah klien tidak kesakitan
  • Keluhan klien berkurang

Intervensi :
  • Kaji riwayat nyeri dan respon terhadap nyeri
  • Kaji kebutuhan yang dapat mengurangi nyeri dan jelaskan tentang teknik mengurangi nyeri dan penyebab nyeri
  • Ciptakan lingkungan yang nyaman (mengganti alat tenun)
  • Kurangi stimulus yang tidak menyenangkan
  • Kolaborasi dengan dokter dalam pemberian analgetik



Diagnosa Keperawatan 2. :
Hipertermi b.d proses infeksi

Tujuan :
Klien akan memiliki suhu tubuh normal

Kriteria Hasil :
  • Suhu 36–37 °C
  • Klien tidak menggigil
  • Klien dapat istirahat dengan tenang

Intervensi :
  • Observasi keadaan umum klien dengan tanda vital tiap 2 jam sekali
  • Berikan antipiretik sesuai anjuran dokter dan monitor keefektifan 30-60 menit kemudian
  • Berikan kompres di dahi dan lengan
  • Anjurkan agar klien menggunakan pakaian yang tipis dan longgar
  • Berikan minum yang banyak pada klien


Diagnosa Keperawatan 3. :
Cemas b.d proses penyakit

Tujuan :
Cemas berkurang atau hilang

Kriteria Hasil :
  • Klien merasa rileks
  • Vital sign dalam keadaan normal
  • Klien dapat menerima dirinya apa adanya

Intervensi :
  • Kaji tingkat ketakutan dengan cara pendekatan dan bina hubungan saling percaya
  • Pertahankan lingkungan yang tenang dan aman serta menjauhkan benda-benda berbahaya
  • Libatkan klien dan keluarga dalam prosedur pelaksanaan dan perawatan
  • Ajarkan penggunaan relaksasi
  • Beritahu tentang penyakit klien dan tindakan yang akan dilakukan secara sederhana.

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