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    Keamanan/Perlindungan: Resiko Perdarahan: Rencana Asuhan Keperawatan (Nursing Care Plan)

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    Ranap Cempaka
    This nursing care plan addresses the risk of bleeding. The nursing diagnosis is risk for bleeding related to various medical conditions and treatments. The goals are to prevent internal and external bleeding. Interventions include monitoring signs of bleeding, administering blood products if needed, avoiding trauma, and preventing constipation. Outcomes involve monitoring for severity and signs of bleeding such as changes in vital signs and hematology levels.

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    Keamanan/Perlindungan: Resiko Perdarahan: Rencana Asuhan Keperawatan (Nursing Care Plan)

    Uploaded by

    Ranap Cempaka
    22 views3 pages
    This nursing care plan addresses the risk of bleeding. The nursing diagnosis is risk for bleeding related to various medical conditions and treatments. The goals are to prevent internal and external bleeding. Interventions include monitoring signs of bleeding, administering blood products if needed, avoiding trauma, and preventing constipation. Outcomes involve monitoring for severity and signs of bleeding such as changes in vital signs and hematology levels.

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    NCP RESIKO PERDARAHAN

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    This nursing care plan addresses the risk of bleeding. The nursing diagnosis is risk for bleeding related to various medical conditions and treatments. The goals are to prevent internal and external bleeding. Interventions include monitoring signs of bleeding, administering blood products if needed, avoiding trauma, and preventing constipation. Outcomes involve monitoring for severity and signs of bleeding such as changes in vital signs and hematology levels.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    22 views3 pages

    Keamanan/Perlindungan: Resiko Perdarahan: Rencana Asuhan Keperawatan (Nursing Care Plan)

    Uploaded by

    Ranap Cempaka
    This nursing care plan addresses the risk of bleeding. The nursing diagnosis is risk for bleeding related to various medical conditions and treatments. The goals are to prevent internal and external bleeding. Interventions include monitoring signs of bleeding, administering blood products if needed, avoiding trauma, and preventing constipation. Outcomes involve monitoring for severity and signs of bleeding such as changes in vital signs and hematology levels.

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    © All Rights Reserved
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    You are on page 1of 3

    RENCANA ASUHAN KEPERAWATAN ( NURSING CARE PLAN )

    KEAMANAN/PERLINDUNGAN : RESIKO PERDARAHAN


    Nursing Diagnosis Resiko perdarahan berhubungan dengan anuriema, circumsisi,kurangnya pengetahuan, DIC, riwayat jatuh,
    ganggan gastrointestinal , trombositopenia, komplikasi post partum, komplikasi kehamilan, trauma, efek
    samping pengobatan, pengobatan, kemoterapi ( Risk for bleeding related to aneurism, circumcisison, deficient
    knowledge, Disseminated Intra Coagulation history of falls, gastro intestinal Disorder ( Gastric ulcer disease,
    polyps, varises), Impaired liver function
    ( cirosis,hepatitis ),inheren coagulapathies ( thrombocytopenia ), post partum complication ( uterine atony,
    retained placenta ), pregnancy related complication e.g placenta previa, molar pregnancy, placenta abrutio),
    trauma, treatment related side effect e.g surgery, medication, chemotheraphy )
    Patient Goal Tidak ada resiko terjadinya perdaragan internal dan eksternal ( No risk Severity of internal or external
    bleeding/hemoragic)
    Intervention ( NIC ) Outcome ( NOC )

    OBSERVASI : Blood loss severity :

    1. Monitor HB dan hematokrit level sebelum, setelah kehilangan darah jika 1. Visible blood loss
    diindikasikan ( Monitor nilai HB, Hematokrit before and after blood loss as 2. Hematuria
    indicated) 3. Frank blood from anus
    2. fibrin, jumlah sel pembekuan darah, jika dibutuhkan ( Monitor coagulation 4. Hemoptysis
    studies, including protrombin time, partial protrombine test , degradation fibrin, 5. Hematemesis
    platelet counts as appropriate) 6. Abdominal ditention
    3. Hindari pengukuran temperature melalui rectal (Avoid taking rectal temperature ) 7. Vaginal bleeding
    4. Monitor tanda dan gejala dari perdarahan menetap ( cek semua sekresi ) Monitor
    sign and syptom of persistent bleeding ( e.g check all secretion )

    SAFETY/PROTECTION : RISK FOR BLEEDING


    Tanggal/Jam :

    Nursing Diagnosis Resiko perdarahan berhubungan dengan anuriema, circumsisi,kurangnya pengetahuan, DIC, riwayat jatuh,
    Page 1 of 3
    KPWT/0165-77 / RAK /13/Rev.0
    ganggan gastrointestinal , trombositopenia, komplikasi post partum, komplikasi kehamilan, trauma, efek
    samping pengobatan, pengobatan, kemoterapi ( Risk for bleeding related to aneurism, circumcisison, deficient
    knowledge, Disseminated Intra Coagulation history of falls, gastro intestinal Disorder ( Gastric ulcer disease,
    polyps, varises), Impaired liver function
    ( cirosis,hepatitis ),inheren coagulapathies ( thrombocytopenia ), post partum complication ( uterine atony,
    retained placenta ), pregnancy related complication e.g placenta previa, molar pregnancy, placenta abrutio),
    trauma, treatment related side effect e.g surgery, medication, chemotheraphy )
    Patient Goal Tidak ada resiko terjadinya perdaragan internal dan eksternal ( No risk Severity of internal or external
    bleeding/hemoragic)
    Intervention ( NIC ) Outcome ( NOC )

    TREATMENT : 8. Post surgical bleeding


    5. Berikan bedrest selama perdaharan aktif ( Obtain bedrest during active bleeding ) 9. Decrease systolic/diastolic pressure
    6. Berikan product darah ( contohnya PRC, atau FFP) jika dibutuhkan ( Administer 10. Increased apical heart rate
    blood products e.g Platelat, fresh frozen plasma as appropriate 11. Loss of body heat
    7. Hindari pasien dari trauma yang dapat mengakibatkan penyebab perdarahan 12. Skin and mucous membrane pallor
    ( Avoid the patient form trauma which may cause bleeding ) 13. Anxiety
    8. Berikan suntikan ( IV,IM atau Sub cutan ) jika dibutuhkan ( injection (IV,IM,or SQ ) 14. Decreased cognition
    as appropriate 15. Decrease HB
    9. Hindari konstipasi e.g menunjang masukan cairan and melunakkan defecasi ) jika Decreased HT
    dibutuhkan ( Avoid constipation eg encourange fluid intake and stool softener )
    as appropriate
    10. Gunakan sikat gigi yang lembut untuk oral care ( Use soft toothbrush or
    toothettes for oral care )
    11. Gunakan elektrik razor untuk bercukur ( Use electric razor, instead or straight
    edge, for shaving )
    12. Hindari procedure invasive jika memungkinkan , monitor perdarahan tertutup
    ( Avoid invasive procedure if they necessary , monitor closely for bleeding )

    Nursing Diagnosis Resiko perdarahan berhubungan dengan anuriema, circumsisi,kurangnya pengetahuan, DIC, riwayat jatuh,
    ganggan gastrointestinal , trombositopenia, komplikasi post partum, komplikasi kehamilan, trauma, efek
    samping pengobatan, pengobatan, kemoterapi ( Risk for bleeding related to aneurism, circumcisison, deficient
    knowledge, Disseminated Intra Coagulation history of falls, gastro intestinal Disorder ( Gastric ulcer disease,
    Page 2 of 3
    polyps, varises), Impaired liver function
    ( cirosis,hepatitis ),inheren coagulapathies ( thrombocytopenia ), post partum complication ( uterine atony,
    retained placenta ), pregnancy related complication e.g placenta previa, molar pregnancy, placenta abrutio),
    trauma, treatment related side effect e.g surgery, medication, chemotheraphy )
    Patient Goal Tidak ada resiko terjadinya perdaragan internal dan eksternal ( No risk Severity of internal or external
    bleeding/hemoragic)
    Intervention ( NIC ) Outcome ( NOC )

    13. Hindari pengukuran temperature melalui rectal (Avoid taking rectal temperature ) Skala Penilaian :
    14. Gunakan matras terapeutik untuk meminimalkan trauma kulit ( Use therapeutic
    mattress to minimize skin trauma) 1. penyimpangan sangat berat dari nilai normal ( severe
    15. Berikan obatan contohnya antasida jika diintruksikan deviation from normal range )
    2. penyimpangan berat dari nilai normal ( substantial
    ( Administer medications eg antasida as appropriate )
    deviation from normal range )
    16. Perintahkan pasien menghindari aspirin atau anti koagulan lainnya
    3. penyimpangan Sedang dari nilai normal ( moderate
    ( instruct pasien avoid aspirin or other anticoagulants) deviation from normal range )
    17. Perintahkan pasien menambah masukan nutrisi yang kaya vitamin K 4. penyimpangan Ringan dari nilai normal ( mild
    ( instruct patient to increase intake of foods rich In vitamin K) deviation from normal range )
    18. Hindari konstipasi e.g menunjang masukan cairan and melunakkan defecasi ) jika 5. Tidak ada penyimpangan dari nilai normal ( no
    dibutuhkan ( Avoid constipation eg encourange fluid intake and stool softener ) deviation from normal range )
    as appropriate
    19. Hindari mengangkat benda berat ( Avoid lifting heavy object )

    Nama perawat Koordinator/PJ shift

    (……………………….) (……………………)

    Page 3 of 3

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