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REFERENCES

Black, J.M. & Hawks, J.H. (2009). Medical Surgical Nursing. Singapore: INC.

Corwin, J. (2009). Buku Saku Patofisiologi. Jakarta: EGC.

Kusuma, H. & Nurarif, A.H. Eds. (2012). NANDA. Yogyakarta.

Muttaqin, A. (2009). Asuhan Keperawatan Klien dengan Gangguan Sistem

Kardiovaskular dan Hematologi. Jakarta: Salemba Medika.

Rendy, M.C. & Margareth, T.H. (2012). Asuhan Keperawatan Medikal Bedah dan
Penyakit Dalam. Yogyakarta: Nuha Medika.

Robbins, K. & Cortan. Eds 7. (2012). Buku Ajar Patologi. Jakarta: EGC

Watson, R. (2011). Anatomy and Physiology for Nurses. Thirteen Edition.

Wijaya, A.S. & Putri, Y.M. (2013). Keperawatan Medikal Bedah. Yogyakarta: Nuha
Medika.

Data Rumah Sakit Umum Dr. H. Mochammad Ansari Saleh ruangan ICCU Infrak
Miokad Akut tahun 2014

Anonim (2013). (Internet). Based on: http://cv-nurse.images.com/2013/02/anatomi-

jantung.html (Accessed on March 13th, 2014)

Anonim (2008). (Internet). Based on: http://repository.usu.ac.id/bitstream/123456789

/Chapter%20I.pdf (Accessed on March 10th, 2014)

Vibhuti (2013). (Internet). Based on: http://emedicine.medscape.com/article/350175-

overview (Accessed on March 16th, 2014)
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Appendix 1

Glasgow Coma Scale (GCS)

Parameter Response Results

Eye Open spontaneously 4
Against voice 3
On pain 2
Not receptors 1

Verbal response Orientation good 5

Confused 4
The words are not clear 3
The sound is not clear 2
Do not respond 1

Motor response/movement Following orders 6

Local movement 5
Flexion, interesting 4
Flexion, abnormal 3
Abnormal extension 2
Not abnormal 1

Source: Priharjo Robert, S.Kp, Msc, RN (2007:170). Pengkajian Fisik Keperawatan

 77

Appendix 2

CONSCIOUSNESS LEVEL

Consciousness Signs
compost mentis Fully conscious, able to answer all questions
about the circumstances surrounding.

Apatis State of consciousness hesitate to get in

touch with the surrounding life, indifferent
attitude.

Samnolen State of consciousness that wants to sleep

alone, can be awakened by pain stimuli, but
fell asleep again.

Delirium Chaotic state motor very rebellious,

screaming and unaware of other people, the
place and time.

Sopor /semikoma State of consciousness that resembles a

coma, only reaction can be induced by
stimulation of pain.

Coma The state of consciousness is lost completely

and can not be awakened by any stimulus

Source: Priharjo Robert, S.Kp, Msc, RN (2007:23). Pengkajian Fisik Keperawatan

 78

Appendix 3

PAIN SCALE

Scale Pain response

0 There is no pain
1 Mild pain
2 Moderate pain
3 Severe pain
4 The pain very severy
5 Colic pain/not tetained

Source: Muttaqin Arif (2008:43) Asuhan Keperawatan dengan Gangguan Sistem

Pernapasan
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Appendix 4
GRADING OF MUSCLE STRENGTH

Scale Normality strength (%) Characteristic

0 0 Total paralysis.

1 10 There is no movement, palpable / visible

muscle contraction.

2 25 Full muscle movement, against gravity

with support.

3 50 Normal movement, against gravity.

Full normal movement, defying gravity

4 75 with a little detention.

5 100 Full normal movement, against gravity

with full containment.

Source: Priharjo Robert, S.Kp, Msc, RN (2007:159). Pengkajian Fisik Keperawatan

 80

Appendix 5
ACTIVITY SCALE

Scale Client activity

0 Independent total
1 Require the use of equipment or tools
2 Require from others to help, supervision, or teaching
3 Need help from another person and equipment or tools
4 Dependence, does not participate

Source: Wilkinson, J.M. & Arhern, N.R (2012:472) Buku Saku Diagnosis
Keperawatan