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ASUHAN KEPERAWATAN PADA TN A: SYOK SEPSIS DENGAN POSISI SEMI-RECUMBENT DI INTENSIVE CARE UNIT RUMAH SAKIT ADVENT BANDUNG

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ABSTRACT NURSING CARE FOR MR. A: SEPTIC SHOCK WITH SEMI-RECUMBENT POSITIONING IN RUMAH SAKIT ADVENT INTENSIVE CARE UNIT Keyzha L. Malinti NIM: 1753041 Septic shock is a common and deadly critical condition with a high mortality rate. This case report was conducted to directly identify clients with septic shock through a comprehensive nursing process. The method used in the preparation of this case report is descriptive method by explaining the nursing care that was done in a patient diagnosed with septic shock in the Rumah Sakit Advent Bandung Intensive Care Unit. Assessment, nursing care planning, nursing intervention, implementation and evaluation according to the theory was done for the patient in four days to improve health. Three major nursing problems was found from the assessment. Impaired gas exchange related to infection, ineffective airway clearance related to excessive mucus, and hyperthermia related to inflammatory response. Observation of vital signs, blood cultures, broad-spectrum antibiotic administration, fluid resuscitation for hypotension, and vasopressor administration. Patient breathes with support of the mechanical ventilator, GCS 11, upper extremity edema, RR= 20-30x/min, HR= 120-140x/min, BP= 90/60- 110/70mmHg, T= 36-38°C, and total bed rest with semi-recumbent position. Septic shock is a severe complication of sepsis and is one of the mortality causes Intensive Care Unit. Complications can aggravate the state of the patient by causing dysfunction of the vital organs in the body, preventing patients from surviving septic shock. Increasing health promotion, accurate assessment, and relevant action is required in nursing care of patients with septic shock. Keywords: Nursing Care, Septic Shock