Asuhan keperawatan pada Pasien dengan HEMOROID
1. Pengertian Hemoroid/Wasir adalah suatu penyakit yang terjadi pada anus di mana bibir anus mengalami bengkak yang kadang disertai pendarahan. Hemoroid dapat diartikan sebagai suatu benjolan yang ada disekitar anus yang didalamnya terdapat pembuluh darah balik (vena), otot dan jaringan ikat elastis. Anus sendiri merupakan suatu muara usus besar tempat keluarnya kotoran hasil dari pencernaan makanan. Hemo Haemoroid adalah bagian vena yang berdilatasi dalam kanal anal (Suddarth and Hemo Bruner – 2001). 2001). Hemoroid adalah pemekaran pembuluh-pembuluh balik poros usus karena bendungan darah eksternal. (Ramli, Ahmad, Dr.Med.2003). 2. Jenis-Jenis / Macam-Macam Wasir / Homoroid / Ambeyen Wasir atau ambeien ada dua macam yaitu: a. Hemoroid Dalam/Interna Pada wasir dalam terdapat pembuluh darah pada anus yang ditutupi oleh selaput lendir yang basah. Jika tidak ditangani bisa terlihat muncul menonjol ke luar seperti wasir luar. Gejala wasir dalam adalah suka ada darah yang keluar dari anus saat bab / buang air besar. Jika sudah parah bisa menonjol keluar dan terus membesar sebesar bola tenis sehingga harus diambil tindakan operasi untuk membuang wasir. Hemoroid Interna menjadi 4 derajat untuk menilai tingkat keparahannya: 1) Grade 1, terjadi perdarahan tetapi tidak ada tonjolan rektum. 2) Grade 2, terjadi tonjolan rektum tetapi bisa masuk kembali dengan sendirinya.
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3) Grade 3, terjadi tonjolan rektum tetapi bisa masuk kembali dengan bantuan tangan. 4) Grade 4, terjadi tonjolan rektum disertai dengan bekuan darah dan tonjolan ini menutupi muara anus. b. Hemoroid Luar/Eksterna Wasir luar merupakan varises di bawah otot yang umumnya berhubungan dengan kulit. Biasanya wasir ini terlihat tonjolan bengkak kebiruan pada pinggir anus yang terasa sakit dan gatal. 3. Hal-Hal / Faktor Pemicu Yang Menyebabkan atau Penyebab Wasir / Ambeien / Hemoroid a. Terlalu banyak duduk b. Diare menahun c. Kehamilan ibu hamil yang diakibatkan perubahan hormon d. Keturunan penderita wasir e. Hubungan seks yang tidak lazim f. Penyakit yang membuat mengejan penderita g. Sembelit / konstipasi / obsitpasi menahun h. Penekanan kembali aliran darah vena, dll. 4. Ciri Khas / Gejala Penyakit Wasir / Ambeien / Hemoroid Sebelum parah sebaiknya kita mengenal seperti apa penyakit wasir ada awal mulanya sehingga kita bisa obati sedini mungkin. Biasanya penderita akan mengalami pendarahan
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ngeden / mengejan yang bisa memperparah wasirnya. Selain itu biasanya anus akan terasa gatal akibat virus dan bakteri yang membuat infeksi. 5. Mengatasi, Mengobati & Menyembuhkan Wasir / Ambeyen / Hemoroid a. Jalankan pola hidup sehat b. Olah raga secara teratur c. Makan makanan berserat d. Hindari terlalu banyak duduk atau nongkrong di wc / toilet e. Jangan merokok, minum minuman keras, narkoba, dll f. Jangan melakukan aktivitas hubungan seks yang tidak wajar g. Minum air yang cukup h. Jangan menahan kencing dan berak i. Jangan suka menggosok dan menggaruk dubur berlebihan j. Jangan mengejan / mengeden / ngeden berlebihan k. Jika tidak ingin pup / bab jangan dipaksa l. Duduk berendam pada air yang hangat m. Minum obat sesuai anjuran dokter
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6. Cara Mengobati Hemoroid a. Meminimalisasi kemungkinan penyebab dari hemoroid tersebut. Bila disebabkan oleh faktor makanan maka dianjurkan untuk mulai mengkonsumsi makanan yang banyak mengandung serat seperti buah buahan, sayur sayuran, padi padian dan sereal. Konsumsi obat pelunak kotoran dan minum yang banyak juga direkomendasikan b. Menggunakan obat obatan antihemoroid. Ada beberapa sediaan obat diantaranya, salep, krim dan tablet anus. c. Operasi. Operasi biasanya dilakukan pada hemoroid yang parah dan sulit diatasi dengan obat obatan. Namun biasanya, walau telah dilakukan operasi, pasien tetap dianjurkan untuk mengkonsumsi makanan yang banyak mengandung serat.
ASUHAN KEPERAWATAN PERIOPERATIF PADA PASIEN DENGAN HEMOROID
A. Asuhan Keperawatan Pra Operasi di Kamar Bedah 1. Biodata Pasien a. Nama a. Nama : Ny. L b. Usia : 26 tahun c. No c. No Registrasi : 156818 d. Ruang : ZH e. Diagnosa Medis : Hemoroid Grade III
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2. Status Kesehatan a. Kesadaran : Compos Mentis b. TTV : 1) TD : 110/70 mmHg 2) N 2) N : 80 x/mnt o
3) T : 36 C 4) RR : 20 x/mnt c. Riwayat Kesehatan Riwayat Kesehatan Dahulu: Klien belum pernah di operasi Riwayat Kesehatan Saat ini: Muncul benjolan di anus, sakit ± 3 bulan yang lalu, nyeri dan berdarah d. Nutrisi d. Nutrisi 1) BB : 43 kg 2) TB : 152 cm e. Cairan Parenteral Infuse sudah terpasang dengan cairan RL f. Kebersihan Colon Lambung
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g. Pencukuran area operasi : sudah dilakukan h. Personal Hygiene (mandi) : sudah i. Pengosongan kandung kemih DC : sudah terpasang j. Baju Operasi : sudah terpakai 3. Persiapan Penunjang Laboratorium : darah lengkap : sudah, antara lain : No
Parameter
Hasil
1
CT
6
2
BT
3
3
Golongan Darah
AB
4
Hb
9,7
5
AL
9800
6
AT
472.000
7
Gula Sewaktu
85
4. Informed Consent : Sudah disetujui dengan Tn. S 5. Definisi dan Pathway : a. Definisi Hemoroid/Wasir adalah suatu penyakit yang terjadi pada anus di mana bibir anus mengalami bengkak yang kadang disertai pendarahan.
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c. Status Psikososial 1) Subjektif : a) Klien mengatakan belum pernah operasi b) Klien mengatakan nyeri sekali untuk duduk dengan skla 8, keluar darah sejak ± 3 bulan yang lalu 2) Objektif a) Ada benjolan di anus b) BAB darah c) Skala nyeri : 8 d) Meringis kesakitan 6. Diagnosa Keperawatan Gangguan rasa nyaman: nyeri berhubungan dengan proses penyakit (hemoroid grade III) dimanifestasikan dengan skala nyeri : 8 7. Rencana Keperawatan
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b. Rencana Tindakan Keperawatan 1) Kaji tingkat nyeri / ketidaknyamanan pada skala 0-10 2) Ajarkan teknik nafas dalam untuk mengurangi nyeri 3) Atur posisi yang nyaman : posisi klien miring c. Implementasi No
1
Implementasi
mengkaji
tingkat
Respon Pasien
nyeri
/ Skala 8
ketidaknyamanan pada skala 0-10 2
Mengkaji
aktivitas
sehari-hari Pasien kooperatif
sebelumnya 3
Mengatur posisi yang nyaman : posisi Klien kooperatif ( klien miring
4
klien miring kiri)
Ajarkan teknik nafas dalam untuk Klien mengurangi nyeri
dalam latihan nafas dalam
B. Perawatan Intra Operasi 1. Persiapan pasien
kooperatif
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d. N d. N : 88 x/mnt 2. Persiapan Alat a. Chromic atraumatik 0 (2) b. Cromatik 1 (1) c. Saturasi O2 d. Cairan RL e. Tensi f. Perlak g. Duk Besar (3) h. Duk kecil (2) i. Calamicityne j. Kasa (10) k. Plester
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r. Klem arteri (10) s. Cocker (4) t. Duk klem (6) u. Nail u. Nail Holder (2) v. Bengkok (2) w. Kom (2) x. Gunting (2) y. Bisturi (1) 3. Pelaksanaan Asisten/Instrumen No
Tindakan
Alat yang disiapkan
1
Atur posisi pasien
Litothomy
2
Mempersempit area operasi
Duk klem, duk besar, duk sedang
3
Antiseptic area operasi
Kasa, betadin, alcohol, klem arteri
4
Klem posisi jam 12, 3, 6, 9
Siap klem
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b. 6 – 9 9 c. 9 – 12 12 9
Mengulangi jahitan memutar sesuai arah Siapkan
benang
jam
atraumatik no. 1
10
Cek perdarahan
kasa
11
Gunakan tampon
Kasa tampon kenicer
12
Operasi selesai, klien dibersihkan
-
13
Pasang DC
Siapkan DC
C. Asuhan Keperawatan Post Operasi di Kamar Bedah 1. Pengkajian post operasi a. Primer A : tidak ada secret, RR: 20 x /mnt B : tidak ada gangguan jalan nafas C : TD : 100/60 mmHg, N : 88 x/mnt, tidak simetris, kemerah-merahan di area operasi b. Pengkajian Sekunder
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Jenis Anastesi : Spinal Anastesi Nilai Bromage score No
Kriteria
Standar
Masuk
Keluar
1.
Gerakan penuh di tungkai
0
0
0
2.
Tidak mampu ekstensi tungkai
1
0
0
3.
Tidak mampu fleksi lutut
2
1
1
4.
Tidak mampu fleksi
3
1
0
pergelangan kaki c. Diagnosa Keperawatan Resiko tinggi cedera berhubungan dengan kesadaran pasien yang belum optimal d. Rencana Keperawatan
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b) Identifikasi faktor lngkungan yang memungkinkan resiko jatuh (posisi pasien senyaman mungkin) c) Pantau tingkat kesadaran pasien dan lakukan RPS yaitu dengan Bromage dengan Bromage score d) Anjurkan untuk makan dan minum langsung setelah operasi e) Anjurkan Bed rest selama 24 jam 3) Implementasi No
Implementasi
Respon Pasien
1
Memantau tingkat kesadaran pasien
Klien Kooperatif
2
Memasang penghalang tempat tidur
Klien Kooperatif
3
Mengajak
klien
berbincang-bincang Klien Kooperatif
(menanyakan nama dan alamat)
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RR : 20 x/mnt
T : 36,5 C
o
b. Kesadaran : Bromage Score: 1, tidak mampu fleksi lutut c. Bngun bila dipanggil d. Gringsang e. Terpasang plang bed. A: masalah teratasi sebagian P: lanjutkan RTL
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KEPERAWATAN PRE OPERATIF A.PENDAHULUAN Keperawatan pre operatif merupakan tahapan awal dari keperawatan perioperatif. Kesuksesan tindakan pembedahan secara keseluruhan sangat tergantung pada fase ini. Hal ini disebabkan fase ini merupakan awalan yang menjadi landasan untuk kesuksesan tahapan-tahapan berikutnya. Kesalahan yang dilakukan pada tahap ini akan berakibat fatal pada tahap berikutnya. Pengakajian secara integral dari fungsi pasien meliputi fungsi fisik biologis dan psikologis sangat diperlukan untuk keberhasilan dan kesuksesan suatu operasi.
B. PERSIAPAN KLIEN DI UNIT PERAWATAN
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3) Keseimbangan cairan dan elektrolit Balance cairan perlu diperhatikan dalam kaitannya dengan input dan output cairan. Demikaian juga kadar elektrolit serum harus berada dalam rentang normal. Kadar elektrolit yang biasanya dilakuakan pemeriksaan diantaranya dalah kadar natrium serum (normal : 135 -145 mmol/l), kadar kalium serum (normal : 3,5 - 5 mmol/l) dan kadar kreatinin serum (0,70 - 1,50 mg/dl). Keseimbangan cairan dan elektrolit terkait erat dengan fungsi ginjal. Dimana ginjal berfungsi mengatur mekanisme asam basa dan ekskresi eksk resi metabolit obat-obatan anastesi. Jika fungsi ginjal baik maka operasi dapat dilakukan dengan baik. Namun jika ginjal mengalami gangguan seperti oliguri/anuria, insufisiensi renal akut, nefritis akut maka operasi harus ditunda menunggu perbaikan fungsi ginjal. Kecuali pada kasus-kasus yang mengancam jiwa. 4) Kebersihan lambung dan kolon Lambung dan kolon harus di bersihkan terlebih dahulu. Intervensi keperawatan yang bisa
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7) Pengosongan kandung kemih Pengosongan kandung kemih dilakukan dengan melakukan pemasangan kateter. Selain untuk pengongan isi bladder tindakan kateterisasi juga diperluka untuk mengobservasi balance cairan. 8) Latihan Pra Operasi Berbagai latihan sangat diperlukan pada pasien sebelum operasi, hal ini sangat penting sebagai persiapan pasien dalam menghadapi kondisi pasca operasi, seperti : nyeri daerah operasi, batuk dan banyak lendir pada tenggorokan.
Latihan yang diberikan pada pasien sebelum operasi antara lain : 1. Latihan Nafas Dalam
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efektif sangat bermanfaat bagi pasien setalah operasi untuk mengeluarkan lendir atau sekret tersebut. Pasien dapat dilatih melakukan teknik batuk efektif dengan cara : 1) Pasien condong ke depan dari posisi semifowler, jalinkan jari-jari tangan dan letakkan melintang diatas incisi sebagai bebat ketika batuk. 2) Kemudian pasien nafas dalam seperti cara nafas dalam (3-5 kali) 3) Segera lakukan batuk spontan, pastikan rongga pernafasan terbuka dan tidak hanya batuk dengan mengadalkan kekuatan tenggorokan saja karena bisa terjadi luka pada tenggorokan. Hal ini bisa menimbulkan ketidaknyamanan, namun tidak berbahaya terhadap incisi. 4) Ulangi lagi sesuai kebutuhan. 5) Jika selama batuk daerah operasi terasa nyeri, pasien bisa menambahkan dengan menggunakan
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Demikian juga faktor usia/penuaan dapat mengakibatkan komplikasi dan merupakan faktor resiko pembedahan. Oleh karena itu sangatlah penting untuk mempersiapkan fisik pasien sebelum dilakukan pembedahan/operasi. Faktor resiko terhadap pembedahan antara lain : 1. Usia Pasien dengan usia yang terlalu muda (bayi/anak-anak) dan usia lanjut mempunyai resiko lebih besar. Hal ini diakibatkan cadangan fisiologis pada usia tua sudah sangat menurun . sedangkan pada bayi dan anak-anak disebabkan oleh karena b elum matur-nya semua fungsi organ. 2. Nutrisi Kondisi malnutrisi dan obesitas/kegemukan lebih beresiko terhadap pembedahan dibandingakan dengan orang normal dengan gizi baik terutama pada fase penyembuhan. Pada orang malnutisi
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terapi kortikosteroid beresiko mengalami insufisinsi adrenal. Pengguanaan oabat -obatan kortikosteroid harus sepengetahuan dokter anastesi dan dokter bedahnya. 5. Merokok
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b) PERSIAPAN PENUNJANG Persiapan penunjang merupakan bagian yang tidak dapat dipisahkan dari tindakan pembedahan. Tanpa adanya hasil pemeriksaan penunjang, maka do kter bedah tidak meungkin
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5. Pemeriksaan KGD dilakukan untuk mengetahui apakah kadar gula darah pasien dalan rentang normal atau tidak. Uji KGD biasanya dilakukan dengan puasa 10 jam (puasa jam 10 malam dan diambil darahnya jam 8 pagi) dan juga dilakukan pemeriksaan KGD 2 jam PP (ppst prandial).
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ASA grade IV Status fisik : Penyakit/gangguan sistemik berat yang menbahayakan jiwa yang tidak
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pemeriksaan, pembedahan serta pembiusan yang akan dijalani. Jika petugas belum menjelaskan secara detail, maka pihak pasien/keluarganya berhak untuk menanyakan kembali sampai betul betul paham. Hal ini sangat penting untuk dilakukan karena jika tidak meka penyesalan akan
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