DEFINITIONSTrauma is an injury / involuntary or psychological or emotional harm (Dorland, 2002).Trauma is a wound or other physical injury or physiological injury caused severe emotional disturbance (Brooker, 2001).Trauma is the leading cause of death in children and adults less than 44 years. Alcohol
and drug abuse has been a factor in the implications of blunt and
penetrating trauma and trauma intentional or unintentional (Smeltzer,
2001).Abdominal
trauma is an injury to the abdomen, can be blunt and penetrating trauma
and trauma intentional or unintentional (Smeltzer, 2001).Abdominal
trauma is an injury to the contents of the abdominal cavity can occur
with or without a break of the abdominal wall where the handling /
management of emergencies is more to be done action laparotomy (School
of Medicine, 1995).
B. Etiology AND CLASSIFICATION1. Penetrating trauma (trauma abdomen with penetration into the peritoneum cavity).Caused by: stab wounds, gunshot wounds.2. Blunt trauma (trauma without penetrating into the abdominal cavity peritoneum).Caused by: blow, collision, explosion, deceleration, compression or seat belt (set-belt) (School of Medicine, 1995).
C. PathophysiologyJab / shot; blow, collision, explosion, deceleration, compression or seat belt (set-belt)-Abdominal Trauma-:1. Blunt abdominal trauma blood loss. Bruising / injury to the abdominal wall. damage organs. Pain irritation intestinal fluid2.Trauma penetrating abdominal The loss of all or part of the function of organs sympathetic stress response bleeding and blood clots Bacterial Contamination cell death
1 & 2 causes:
Damage to skin integrity
Shock and hemorrhage
Damage to gas exchange
High risk of infection
Acute pain (Faculty, 1995).
D. SIGNS AND SYMPTOMS1. Penetrating trauma (trauma abdomen with penetration into the peritoneum cavity): The loss of all or part of the function of organs sympathetic stress response bleeding and blood clots Bacterial Contamination cell death2. Blunt trauma (trauma without penetrating into the abdominal cavity peritoneum). blood loss. Bruising / injury to the abdominal wall. damage organs. tenderness, pain of word, off pain and stiffness (rigidity) abdominal wall. irritation intestinal fluid (School of Medicine, 1995).
E. COMPLICATIONS Soon: hemorrhage, shock, and injury. Slow: infection (Smeltzer, 2001).
F. DIAGNOSTIC EXAMINATION rectal examination: presence of blood indicates abnormalities in the large intestine; kuldosentesi, the possibility of the presence of blood in the stomach, and catheterization, the blood showed a lesion in the urinary tract. Laboratory: hemoglobin, hematocrit, leukocytes and urine analysis. radiology: when indicated to do a laparotomy. IVP / sistogram: only when there is suspicion of urinary tract trauma. abdominal paracentesis: This action is done in blunt abdominal trauma who doubt that defects in the abdominal cavity or abdominal blunt trauma accompanied with severe head trauma, performed by using needle puncture no 18 or 20 which is inserted through the abdominal wall or underlined lower quadrant area middle under center with rubbing jar first. peritoneal Lavase: puncture and aspiration / flushing the abdominal cavity with saline fluid entering through a cannula inserted into the cavity of the peritoneum (School of Medicine, 1995).
G. MANAGEMENT Emergency Management; ABCDE.Installation NGT for gastric emptying and prevent aspiration. catheter to empty the bladder mounted and assess the urine comes out (bleeding). surgery / laparotomy (for penetrating trauma and blunt trauma in case of peritoneal stimulation: shock; bowel sounds are not audible; prolapsed viscera through a stab wound; blood in the stomach, bladder, rectum; intraperitoneal free air; lavase positive peritoneal; fluid free in abdominal cavity) (School of Medicine, 1995).
NURSING MANAGEMENTA. ASSESSMENTAssessment is the first step in the nursing process and basic overall (Boedihartono, 1994).Assessment of abdominal trauma patients (Smeltzer, 2001) are included:1. Penetrating Abdominal Trauma Get a history mechanism of injury; strength jab / shot; blunt force (punches). inspection abdomen for signs of injury before: puncture injuries, bruises, and a bullet exit.Auscultation presence / absence of bowel sounds and record baseline data so that changes can be detected. Absence of bowel sounds is an early sign of intraperitoneal involvement: if there are signs of irritation peritoneum, usually performed laparotomy (surgical incision into the abdominal cavity). Assess patients for progression of abdominal distension, move to protect, tenderness, stiffness or aching muscles loose, decreased bowel sounds, hypotension, and shock. Assess chest injury that often follow an intra-abdominal injury, injury-related observations. Record all physical signs during patient examinations.
2. Blunt abdominal trauma Get detailed history if possible (often can not be obtained, inaccurate, or false). get all possible data about the following things:• Method of injury.• Time of onset of symptoms.• What if the passenger traffic accidents (driver often suffers ruptured spleen or liver). Safety belt use / not, restrain the type used.• eat or drink last time.• bleeding tendency.• latest danmedikasi disease.• immunization history, with attention to tetanus.• Allergies. Do a quick check on the entire body pasienuntuk detect life-threatening problems.
EMERGENCY MANAGEMENT1. Started resuscitation procedures (repair of the airway, breathing, circulation) as indicated.2. Keep the patient on a gurney or stretcher board; motion can cause fragmentation clot in the large veins and cause massive hemorrhage.a) Ensure kepatenan airway and breathing as well as the stability of the nervous system.b) If the patient is comatose, dislocated neck to neck obtained after x-rays.c) Cut out clothes from the wound.d) Calculate the number of injuries.e) Determine the location of entrance and exit wounds.3. Assess signs and symptoms of hemorrhage. Hemorrhage often accompanies abdominal injuries, especially liver and spleen trauma.4. Control bleeding and blood volume defense until surgery is performed.a) Provide external compression on the bleeding wound and chest injuries dam.b) Put a large diameter catheter for IV fluid replacement quickly and improve circulation dynamics.c) Note the initial response syoksetelah incident happened to transfusion; This is often a sign of internal perdarrahan.d) The doctor may perform paracentesis to identify the bleeding site.5. Gastric aspiration with a nasogastric tube. This procedure helps detect ulcers, reducing contamination of the peritoneum cavity and prevent lung complications due to aspiration.6. Cover the abdominal viscera came out with a bandage sterile, moist saline dressings to prevent nkekeringan viscera.a) Fleksikan knee patients; protusi prevent further this position.b) Delay administration of oral fluids to prevent increased peristalsis and vomiting.7. Put settle urethral catheter to obtain assurance hematuria and monitor urine output.8. Maintain a continuous flow sheet of vital signs, urine output, central venous pressure readings of patients (if indicated), hematocrit value, and neurologic status.9. Prepare for paracentesis or peritoneum lavase when there is uncertainty about intraperitonium bleeding.10. Prepare sinografi to determine whether there is penetration of the peritoneum in cases of stab wounds.a) Stitches done around the wound.b) a small catheter is inserted into the wound.c) Agents contrast through a catheter inserted; indicate whether the x-ray penetration peritoneum has been done.11. Give tetanus prophylaxis according to regulations.12. Give broad spectrum antibiotics to prevent infection. trauma can lead to infection due to damage caused by a mechanical barrier, exogenous bacteria from the environment at the time of injury and diagnostic and therapeutic maneuvers (nosocomial infections).13. Prepare patients for surgery if there is evidence of shock, blood loss, presence of free air under the diaphragm, eviserasi, or hematuria.
ADVANCED CARE MANAGEMENT diruangB. Nursing DiagnosisNursing diagnosis is a unification of the problem of real or potential patients based on the data that has been collected (Boedihartono, 1994).Nursing diagnoses in patients with abdominal trauma (Wilkinson, 2006) are:1. Damage to skin integrity related to puncture injury.2. High risk of infection associated with impaired skin integrity.3. Acute pain associated with traumatic / discontinuity network.4. Activity intolerance related to general weakness.5. Barriers to physical mobility related to pain / discomfort, activity restriction therapy, and decreased strength / resistance.
C. INTERVENTION AND IMPLEMENTATIONIntervention is planning nursing actions that will be implemented to address the problem in accordance with the nursing diagnoses (Boedihartono, 1994).Implementation is the realization of management and nursing plans that had been developed at the planning stage (Effendi, 1995).And implementation of nursing interventions that occur in patients with abdominal trauma (Wilkinson, 2006) include:1. Damage to skin integrity is the state of one's skin that changes are not desirable.Goal: Achieve wound healing at the appropriate time.Results Criteria: - no signs of infection such as pus.- Do not clean the wound moist and not dirty.- Vital signs are within normal limits or tolerable.Intervention and Implementation:a. Assess skin and wound identification at this stage of development.R / know the extent of injuries facilitate the development of appropriate action.b. Assess the location, size, color, odor, and the number and type of wound fluid.R / identify the severity of the injury will facilitate intervention.c. Monitor the increase in body temperature.R / increased body temperature can be identified as the process of inflammation.d. Provide wound care with aseptic technique. Dressing the wound with sterile gauze and a dry, use paper tape.R / aseptic technique helps accelerate wound healing and prevent infection.e. If recovery does not occur collaboration further action, such as debridement.R / to be foreign or infected tissue is not widespread in other areas of normal skin.f. After debridement, dressing bandage as needed.R / dressing can be substituted one or two times a day depending on the condition of severe / not his wounds, to prevent infection.g. Collaboration antibiotics as indicated.R / antibiotics to kill pathogenic microorganisms useful in areas at risk of infection.
2. The risk of infection associated with inadequate peripheral defense, circulation changes, high blood sugar levels, invasive procedures and skin damage.Objective: infection does not occur / controlled.Criteria results: - there are no signs of infection such as pus.- Do not clean the wound moist and not dirty.- Vital signs are within normal limits or tolerable.Intervention and Implementation:a. Monitor vital signs.R / identify the signs of inflammation, especially when the body temperature rises.b. Perform wound care with aseptic technique.R / controlling the spread of pathogenic microorganisms.c. Perform maintenance on invasive procedures such as intravenous fluids, catheters, wound drainage, etc..R / to reduce the risk of nosocomial infection.d. If signs of infection collaboration for blood tests, such as hemoglobin and leukocytes.R / Hb decrease and increase in the number of normal leukocytes may result from the occurrence of the infection process.e. Collaboration for antibiotics.R / antibiotics to prevent the development of pathogenic microorganisms.
3. Pain is a sensory and emotional experience that is unpleasant and increased as a result of actual or potential tissue damage, described in terms of such damage; onset sudden or slowly from heavy to light intensity samapai can end in anticipation or less predictable and duration of six months.Purpose: The pain can be reduced or lost.Results Criteria: - Pain is reduced or lost- The client seemed calm.Intervention and Implementation:a. Approach the client and familyR / client relationship that makes both cooperative and familyb. Assess the level of intensity and frequency of painR / level of pain intensity and pain frequency scale showsc. Explain to the client the cause of painR / explanation would add to the knowledge of the client's paind. Observation of vital signs.R / to find out the client's developmente. Collaboration with the medical team in the delivery of analgesicsR / is dependent nursing actions, which serves to block the analgesic pain stimulation.
4. Activity intolerance is a condition is an individual who does not quite have the physiological or psychological energy to endure or meet the needs or daily activities desired.Purpose: The patient has enough energy to move.Criteria results: - Behavioral reveals the ability to meet the needs of self.- Patients expressed able to do some activities without assistance.- Coordination of muscle, bone and other limbs either.Intervention and Implementation:a. Plan adequate rest periods.R / reducing activity is not required, and the energy collected can be used for optimal activity secar necessary.b. Provide training activity gradually.R / stages are given to help the process of the activity slowly with energy saving but the exact purpose, early mobilization.c. Aids in meeting the needs of patients as needed.R / reduces energy consumption up to force the patient to recover.d. After reviewing the exercises and activities of the patient's response.R / keep the possibility of an abnormal response of the body as a result of the exercise.
5. Barriers to physical mobility is a limitation in self-reliance, beneficial physical movement of the body or a limb or more.Goal: patient will indicate the optimal level of mobility.Criteria results: - appearance of a balanced ..- Do the movement and displacement.- Maintaining optimal mobility that can be tolerated, with the characteristics: 0 = independent full 1 = require aid. 2 = requires assistance from another person for assistance, supervision, and teaching. 3 = needs help from others and aid. 4 = dependence; did not participate in the activity.Intervention and Implementation:a. Assess the need for health care and the need for equipment.R / identify the problem, facilitate intervention.b. Determine the patient's level of motivation to perform the activity.R / affecting the assessment of the ability of the activity is due to the inability or unwillingness.c. Teach and monitor patients in the use of tools.R / judge limits the ability of optimal activity.d. Teach and support patients in active and passive ROM exercises.R / maintain / increase muscle strength and endurance.e. Collaboration with a physical or occupational therapist.R / as a source suaatu planning to develop and maintain / improve patient mobility.
D. EVALUATIONAddalah evaluation stage on the nursing process in which the degree of success in achieving the goals of nursing assessed and the need to modify or nursing intervention defined purpose (Brooker, 2001).Evaluation expected in patients with abdominal trauma are:1. Achieve wound healing at the appropriate time.2. Infection does not occur / controlled.3. Pain can be reduced or lost.4. Patients have enough energy to move.5. Patients will show optimum level of mobility.
REFERENCESBoedihartono, 1994, Nursing Process in Hospital, Jakarta.Brooker, Christine. , 2001. Pocket Dictionary of Nursing Ed.31. EGC: Jakarta.Dorland, W. A. Newman. , 2002. Medical Dictionary. EGC: Jakarta.Faculty of medicine. , 1995. Science Lecture surgical set. Binarupa Literacy: JakartaNasrul Effendi, 1995, Introduction to Nursing Process, EGC, Jakarta.Smeltzer, Suzanne C. , 2001. Medical-Surgical Nursing Brunner and Suddarth Ed.8 Vol.3. EGC: Jakarta.
B. Etiology AND CLASSIFICATION1. Penetrating trauma (trauma abdomen with penetration into the peritoneum cavity).Caused by: stab wounds, gunshot wounds.2. Blunt trauma (trauma without penetrating into the abdominal cavity peritoneum).Caused by: blow, collision, explosion, deceleration, compression or seat belt (set-belt) (School of Medicine, 1995).
C. PathophysiologyJab / shot; blow, collision, explosion, deceleration, compression or seat belt (set-belt)-Abdominal Trauma-:1. Blunt abdominal trauma blood loss. Bruising / injury to the abdominal wall. damage organs. Pain irritation intestinal fluid2.Trauma penetrating abdominal The loss of all or part of the function of organs sympathetic stress response bleeding and blood clots Bacterial Contamination cell death
1 & 2 causes:
Damage to skin integrity
Shock and hemorrhage
Damage to gas exchange
High risk of infection
Acute pain (Faculty, 1995).
D. SIGNS AND SYMPTOMS1. Penetrating trauma (trauma abdomen with penetration into the peritoneum cavity): The loss of all or part of the function of organs sympathetic stress response bleeding and blood clots Bacterial Contamination cell death2. Blunt trauma (trauma without penetrating into the abdominal cavity peritoneum). blood loss. Bruising / injury to the abdominal wall. damage organs. tenderness, pain of word, off pain and stiffness (rigidity) abdominal wall. irritation intestinal fluid (School of Medicine, 1995).
E. COMPLICATIONS Soon: hemorrhage, shock, and injury. Slow: infection (Smeltzer, 2001).
F. DIAGNOSTIC EXAMINATION rectal examination: presence of blood indicates abnormalities in the large intestine; kuldosentesi, the possibility of the presence of blood in the stomach, and catheterization, the blood showed a lesion in the urinary tract. Laboratory: hemoglobin, hematocrit, leukocytes and urine analysis. radiology: when indicated to do a laparotomy. IVP / sistogram: only when there is suspicion of urinary tract trauma. abdominal paracentesis: This action is done in blunt abdominal trauma who doubt that defects in the abdominal cavity or abdominal blunt trauma accompanied with severe head trauma, performed by using needle puncture no 18 or 20 which is inserted through the abdominal wall or underlined lower quadrant area middle under center with rubbing jar first. peritoneal Lavase: puncture and aspiration / flushing the abdominal cavity with saline fluid entering through a cannula inserted into the cavity of the peritoneum (School of Medicine, 1995).
G. MANAGEMENT Emergency Management; ABCDE.Installation NGT for gastric emptying and prevent aspiration. catheter to empty the bladder mounted and assess the urine comes out (bleeding). surgery / laparotomy (for penetrating trauma and blunt trauma in case of peritoneal stimulation: shock; bowel sounds are not audible; prolapsed viscera through a stab wound; blood in the stomach, bladder, rectum; intraperitoneal free air; lavase positive peritoneal; fluid free in abdominal cavity) (School of Medicine, 1995).
NURSING MANAGEMENTA. ASSESSMENTAssessment is the first step in the nursing process and basic overall (Boedihartono, 1994).Assessment of abdominal trauma patients (Smeltzer, 2001) are included:1. Penetrating Abdominal Trauma Get a history mechanism of injury; strength jab / shot; blunt force (punches). inspection abdomen for signs of injury before: puncture injuries, bruises, and a bullet exit.Auscultation presence / absence of bowel sounds and record baseline data so that changes can be detected. Absence of bowel sounds is an early sign of intraperitoneal involvement: if there are signs of irritation peritoneum, usually performed laparotomy (surgical incision into the abdominal cavity). Assess patients for progression of abdominal distension, move to protect, tenderness, stiffness or aching muscles loose, decreased bowel sounds, hypotension, and shock. Assess chest injury that often follow an intra-abdominal injury, injury-related observations. Record all physical signs during patient examinations.
2. Blunt abdominal trauma Get detailed history if possible (often can not be obtained, inaccurate, or false). get all possible data about the following things:• Method of injury.• Time of onset of symptoms.• What if the passenger traffic accidents (driver often suffers ruptured spleen or liver). Safety belt use / not, restrain the type used.• eat or drink last time.• bleeding tendency.• latest danmedikasi disease.• immunization history, with attention to tetanus.• Allergies. Do a quick check on the entire body pasienuntuk detect life-threatening problems.
EMERGENCY MANAGEMENT1. Started resuscitation procedures (repair of the airway, breathing, circulation) as indicated.2. Keep the patient on a gurney or stretcher board; motion can cause fragmentation clot in the large veins and cause massive hemorrhage.a) Ensure kepatenan airway and breathing as well as the stability of the nervous system.b) If the patient is comatose, dislocated neck to neck obtained after x-rays.c) Cut out clothes from the wound.d) Calculate the number of injuries.e) Determine the location of entrance and exit wounds.3. Assess signs and symptoms of hemorrhage. Hemorrhage often accompanies abdominal injuries, especially liver and spleen trauma.4. Control bleeding and blood volume defense until surgery is performed.a) Provide external compression on the bleeding wound and chest injuries dam.b) Put a large diameter catheter for IV fluid replacement quickly and improve circulation dynamics.c) Note the initial response syoksetelah incident happened to transfusion; This is often a sign of internal perdarrahan.d) The doctor may perform paracentesis to identify the bleeding site.5. Gastric aspiration with a nasogastric tube. This procedure helps detect ulcers, reducing contamination of the peritoneum cavity and prevent lung complications due to aspiration.6. Cover the abdominal viscera came out with a bandage sterile, moist saline dressings to prevent nkekeringan viscera.a) Fleksikan knee patients; protusi prevent further this position.b) Delay administration of oral fluids to prevent increased peristalsis and vomiting.7. Put settle urethral catheter to obtain assurance hematuria and monitor urine output.8. Maintain a continuous flow sheet of vital signs, urine output, central venous pressure readings of patients (if indicated), hematocrit value, and neurologic status.9. Prepare for paracentesis or peritoneum lavase when there is uncertainty about intraperitonium bleeding.10. Prepare sinografi to determine whether there is penetration of the peritoneum in cases of stab wounds.a) Stitches done around the wound.b) a small catheter is inserted into the wound.c) Agents contrast through a catheter inserted; indicate whether the x-ray penetration peritoneum has been done.11. Give tetanus prophylaxis according to regulations.12. Give broad spectrum antibiotics to prevent infection. trauma can lead to infection due to damage caused by a mechanical barrier, exogenous bacteria from the environment at the time of injury and diagnostic and therapeutic maneuvers (nosocomial infections).13. Prepare patients for surgery if there is evidence of shock, blood loss, presence of free air under the diaphragm, eviserasi, or hematuria.
ADVANCED CARE MANAGEMENT diruangB. Nursing DiagnosisNursing diagnosis is a unification of the problem of real or potential patients based on the data that has been collected (Boedihartono, 1994).Nursing diagnoses in patients with abdominal trauma (Wilkinson, 2006) are:1. Damage to skin integrity related to puncture injury.2. High risk of infection associated with impaired skin integrity.3. Acute pain associated with traumatic / discontinuity network.4. Activity intolerance related to general weakness.5. Barriers to physical mobility related to pain / discomfort, activity restriction therapy, and decreased strength / resistance.
C. INTERVENTION AND IMPLEMENTATIONIntervention is planning nursing actions that will be implemented to address the problem in accordance with the nursing diagnoses (Boedihartono, 1994).Implementation is the realization of management and nursing plans that had been developed at the planning stage (Effendi, 1995).And implementation of nursing interventions that occur in patients with abdominal trauma (Wilkinson, 2006) include:1. Damage to skin integrity is the state of one's skin that changes are not desirable.Goal: Achieve wound healing at the appropriate time.Results Criteria: - no signs of infection such as pus.- Do not clean the wound moist and not dirty.- Vital signs are within normal limits or tolerable.Intervention and Implementation:a. Assess skin and wound identification at this stage of development.R / know the extent of injuries facilitate the development of appropriate action.b. Assess the location, size, color, odor, and the number and type of wound fluid.R / identify the severity of the injury will facilitate intervention.c. Monitor the increase in body temperature.R / increased body temperature can be identified as the process of inflammation.d. Provide wound care with aseptic technique. Dressing the wound with sterile gauze and a dry, use paper tape.R / aseptic technique helps accelerate wound healing and prevent infection.e. If recovery does not occur collaboration further action, such as debridement.R / to be foreign or infected tissue is not widespread in other areas of normal skin.f. After debridement, dressing bandage as needed.R / dressing can be substituted one or two times a day depending on the condition of severe / not his wounds, to prevent infection.g. Collaboration antibiotics as indicated.R / antibiotics to kill pathogenic microorganisms useful in areas at risk of infection.
2. The risk of infection associated with inadequate peripheral defense, circulation changes, high blood sugar levels, invasive procedures and skin damage.Objective: infection does not occur / controlled.Criteria results: - there are no signs of infection such as pus.- Do not clean the wound moist and not dirty.- Vital signs are within normal limits or tolerable.Intervention and Implementation:a. Monitor vital signs.R / identify the signs of inflammation, especially when the body temperature rises.b. Perform wound care with aseptic technique.R / controlling the spread of pathogenic microorganisms.c. Perform maintenance on invasive procedures such as intravenous fluids, catheters, wound drainage, etc..R / to reduce the risk of nosocomial infection.d. If signs of infection collaboration for blood tests, such as hemoglobin and leukocytes.R / Hb decrease and increase in the number of normal leukocytes may result from the occurrence of the infection process.e. Collaboration for antibiotics.R / antibiotics to prevent the development of pathogenic microorganisms.
3. Pain is a sensory and emotional experience that is unpleasant and increased as a result of actual or potential tissue damage, described in terms of such damage; onset sudden or slowly from heavy to light intensity samapai can end in anticipation or less predictable and duration of six months.Purpose: The pain can be reduced or lost.Results Criteria: - Pain is reduced or lost- The client seemed calm.Intervention and Implementation:a. Approach the client and familyR / client relationship that makes both cooperative and familyb. Assess the level of intensity and frequency of painR / level of pain intensity and pain frequency scale showsc. Explain to the client the cause of painR / explanation would add to the knowledge of the client's paind. Observation of vital signs.R / to find out the client's developmente. Collaboration with the medical team in the delivery of analgesicsR / is dependent nursing actions, which serves to block the analgesic pain stimulation.
4. Activity intolerance is a condition is an individual who does not quite have the physiological or psychological energy to endure or meet the needs or daily activities desired.Purpose: The patient has enough energy to move.Criteria results: - Behavioral reveals the ability to meet the needs of self.- Patients expressed able to do some activities without assistance.- Coordination of muscle, bone and other limbs either.Intervention and Implementation:a. Plan adequate rest periods.R / reducing activity is not required, and the energy collected can be used for optimal activity secar necessary.b. Provide training activity gradually.R / stages are given to help the process of the activity slowly with energy saving but the exact purpose, early mobilization.c. Aids in meeting the needs of patients as needed.R / reduces energy consumption up to force the patient to recover.d. After reviewing the exercises and activities of the patient's response.R / keep the possibility of an abnormal response of the body as a result of the exercise.
5. Barriers to physical mobility is a limitation in self-reliance, beneficial physical movement of the body or a limb or more.Goal: patient will indicate the optimal level of mobility.Criteria results: - appearance of a balanced ..- Do the movement and displacement.- Maintaining optimal mobility that can be tolerated, with the characteristics: 0 = independent full 1 = require aid. 2 = requires assistance from another person for assistance, supervision, and teaching. 3 = needs help from others and aid. 4 = dependence; did not participate in the activity.Intervention and Implementation:a. Assess the need for health care and the need for equipment.R / identify the problem, facilitate intervention.b. Determine the patient's level of motivation to perform the activity.R / affecting the assessment of the ability of the activity is due to the inability or unwillingness.c. Teach and monitor patients in the use of tools.R / judge limits the ability of optimal activity.d. Teach and support patients in active and passive ROM exercises.R / maintain / increase muscle strength and endurance.e. Collaboration with a physical or occupational therapist.R / as a source suaatu planning to develop and maintain / improve patient mobility.
D. EVALUATIONAddalah evaluation stage on the nursing process in which the degree of success in achieving the goals of nursing assessed and the need to modify or nursing intervention defined purpose (Brooker, 2001).Evaluation expected in patients with abdominal trauma are:1. Achieve wound healing at the appropriate time.2. Infection does not occur / controlled.3. Pain can be reduced or lost.4. Patients have enough energy to move.5. Patients will show optimum level of mobility.
REFERENCESBoedihartono, 1994, Nursing Process in Hospital, Jakarta.Brooker, Christine. , 2001. Pocket Dictionary of Nursing Ed.31. EGC: Jakarta.Dorland, W. A. Newman. , 2002. Medical Dictionary. EGC: Jakarta.Faculty of medicine. , 1995. Science Lecture surgical set. Binarupa Literacy: JakartaNasrul Effendi, 1995, Introduction to Nursing Process, EGC, Jakarta.Smeltzer, Suzanne C. , 2001. Medical-Surgical Nursing Brunner and Suddarth Ed.8 Vol.3. EGC: Jakarta.
Definition
Decubitus ulcers is the destruction or death of the tissue under the skin to the skin even through the muscle to the bone, due to the emphasis on an area basis constantly - constantly causing disruption of blood circulation.Decubitus ulcers are ulcers caused due to intense pressure by the weight on the bed.Decubitus wound was necrosis of the soft tissue between the bones bulges and solid surfaces, most commonly due to immobilization.
Etiologya) Pressureb) Humidityc) Friction
PathophysiologyPressure immobilization time will result in pressure sores, if one part of the body is on a gradient (the difference between the two pressure points). Deeper tissue near the bone, especially muscle tissue with a good blood supply will shift towards lower gradient, while the skin is maintained at the contact surface by increasing friction with the presence of moisture, this condition causes blood vessels stretch and angggulasi (micro circulation) in blood and tissue shear forces experienced in, this will be the ischemia and necrosis before continuing to the skin.
Clinical Manifestations and Complicationsa) The initial injury is a reddish mark which does not disappear when pressed thumb.b) In more severe injuries encountered skin ulcers.c) May present pain and signs of systemic inflammation, including fever and increased white blood cell count.d) infection can occur as a result of weakness and hospitalization is prolonged even on a small ulcer.
Diagnostic Examinationa) Culture: artificial microorganism growth or cell - the cell network.b) Serum Albumin: The main protein in plasma and other serous fluid.
Medical managementa) Changing the position of the patient is bed rest.b) Eliminate pressure on reddened skin and a clean bandage placement and thin when it is shaped decubitus ulcers.c) Systemic: broad spectrum antibiotics, such as: Amoxilin 4x500 mg for 15-30 days. Siklosperm 1-2 grams for 3-10 days. Topical: antibiotic ointment such as kloramphenikol 2 grams.
Nursing Management1.Pengkajiana) The activity / restSigns: decreased strength, endurance, range limitations gerak.pada area of pain disorders such as muscular buds change.b) CirculationSigns: hypoxia, decreased peripheral pulse distal extremity injuries, general peripheral vasoconstriction with loss of pulse, white and cold, tissue edema formation.c) EliminationSigns: decreased urine output is the absence of the emergency phase, the color may be reddish black, if so, identify potentially damage the muscle.d) food / fluidSigns: general tissue edema, anorexia, nausea and vomiting.e) NeurosensoriSymptoms: area numb / tinglingf) RespiratorySymptoms: decreased function of the spinal cord, cord edema, neurological damage, paralysis of respiratory and abdominal muscles.g) Integrity egoSymptoms: family problems, work, finances, disability.Signs: anxiety, crying, dependence, self mmenarik, angry.h) SecuritySigns: a fracture due to the location (fall, accident, tetanik muscle contraction, until the electric shock).
2.Diagnosa Nursing1) Damage to tissue integrity related to mechanical tissue destruction secondary to pressure, friction and faction.2) Damage to physical mobility related to limitation of movement required, the status of which is conditioned, loss of motor control due to changes in mental status.3) Changes in nutrition less than body requirements related to inability of oral intake.4) High risk of infection associated with decubitus basic exposure, suppression of inflammatory responses.5) High risk for ineffective management of therapeutic regimen related to insufficient knowledge of the etiology, prevention, treatment and care at home.
3.Intervensi and Implementation1) Damage to tissue integrity related to mechanical tissue destruction secondary to pressure, friction and faction.- Apply principles of prevention of decubitus sores.R: the precautionary principle decubitus sores, covers reduce or rotate the pressure of the soft tissue.- Set posis patients as comfortable as possible.R: minimizing the occurrence of pressure sores affected tissue.- Wrap the wound with a bandage that retains moisture on the wound environment.R: moist wound healing can accelerate.
2) Damage to physical mobility related to limitation of movement required, the status of which is conditioned, loss of motor control due to changes in mental status.- Support the mobilization of a higher level.R: regular motion consistent relieving pressure on bone protrusions.- Assist / encourage self care / hygiene, such as bathing.R: increased muscle strength and circulation, increase patient control of health improvement in the situation and the environment.- Pay particular attention to the skin.R: research shows that skin is very susceptible to damage due to the weight concentration.
3) Changes in nutrition less than body requirements related to inability of oral intake.- Give preformance eat small amounts, often and in a warm state.R: help prevent gastric distension / discomfort and increase intake, increase appetite.- Help oral hygiene before meals.R: oral / clean equipment increased appetite good.- Maintain strict calorie.R: precise guidelines for the proper calorie intake.
4) High risk of infection associated with decubitus basic exposure, suppression of inflammatory responses.- Use the proper technique for changing a bandage.R: good technique reduces the entry of pathogenic microorganisms into the wound. Measure signs - vital signs.R: an increase in body temperature, tachycardia showed the presence of sepsis.- Use sterile gloves every bandage change.R: every ulcers contaminated by different microorganisms, these measures can prevent infection.- Wash the wound with 0.9% NaCl solution.R: Can get rid of dead tissue on the surface of the skin and reducing microorganisms.- Give the antibiotic medication as indicated.R: decubitus ulcers pilihanpada useful antibiotics against gram-negative organisms and gram positive.
5) High risk for ineffective management of therapeutic regimen related to insufficient knowledge of the etiology, prevention, treatment and care at home.- Encourage measures to prevent decubitus sores.R: injury prevention is easier than treatment of pressure sores.- Encourage measures to treat decubitus sores.R: This specific instructions to help patients and families learn to improve healing and prevent infection.
4. Evaluation1) Patients can prevent and identify factors causing decubitus sores; shows the progress of healing.2) patients had skin without neritema and not pale.3) The patient showed an increase in body weight and muscle mass.4) Leather will not teritasi due exposure to fecal or urine drainage.5) Demonstrate effective learning outcomes for the purpose of repatriation and patient care at home.
REFERENCESCapernito, Linda Juall. , 1999. Plans and Documentation Nursing Diagnosis: Nursing Diagnosis and Collaborative Problems Ed.2. Jakarta: EGC.Doenges, Marilynn E. In 2000. Nursing Plans: Guidelines for Planning and Documenting Patient Care. Jakarta: EGC.Nurachman, Elly. , 2001. Nutrition In Nursing. Jakarta: Sagung Seto.
Decubitus ulcers is the destruction or death of the tissue under the skin to the skin even through the muscle to the bone, due to the emphasis on an area basis constantly - constantly causing disruption of blood circulation.Decubitus ulcers are ulcers caused due to intense pressure by the weight on the bed.Decubitus wound was necrosis of the soft tissue between the bones bulges and solid surfaces, most commonly due to immobilization.
Etiologya) Pressureb) Humidityc) Friction
PathophysiologyPressure immobilization time will result in pressure sores, if one part of the body is on a gradient (the difference between the two pressure points). Deeper tissue near the bone, especially muscle tissue with a good blood supply will shift towards lower gradient, while the skin is maintained at the contact surface by increasing friction with the presence of moisture, this condition causes blood vessels stretch and angggulasi (micro circulation) in blood and tissue shear forces experienced in, this will be the ischemia and necrosis before continuing to the skin.
Clinical Manifestations and Complicationsa) The initial injury is a reddish mark which does not disappear when pressed thumb.b) In more severe injuries encountered skin ulcers.c) May present pain and signs of systemic inflammation, including fever and increased white blood cell count.d) infection can occur as a result of weakness and hospitalization is prolonged even on a small ulcer.
Diagnostic Examinationa) Culture: artificial microorganism growth or cell - the cell network.b) Serum Albumin: The main protein in plasma and other serous fluid.
Medical managementa) Changing the position of the patient is bed rest.b) Eliminate pressure on reddened skin and a clean bandage placement and thin when it is shaped decubitus ulcers.c) Systemic: broad spectrum antibiotics, such as: Amoxilin 4x500 mg for 15-30 days. Siklosperm 1-2 grams for 3-10 days. Topical: antibiotic ointment such as kloramphenikol 2 grams.
Nursing Management1.Pengkajiana) The activity / restSigns: decreased strength, endurance, range limitations gerak.pada area of pain disorders such as muscular buds change.b) CirculationSigns: hypoxia, decreased peripheral pulse distal extremity injuries, general peripheral vasoconstriction with loss of pulse, white and cold, tissue edema formation.c) EliminationSigns: decreased urine output is the absence of the emergency phase, the color may be reddish black, if so, identify potentially damage the muscle.d) food / fluidSigns: general tissue edema, anorexia, nausea and vomiting.e) NeurosensoriSymptoms: area numb / tinglingf) RespiratorySymptoms: decreased function of the spinal cord, cord edema, neurological damage, paralysis of respiratory and abdominal muscles.g) Integrity egoSymptoms: family problems, work, finances, disability.Signs: anxiety, crying, dependence, self mmenarik, angry.h) SecuritySigns: a fracture due to the location (fall, accident, tetanik muscle contraction, until the electric shock).
2.Diagnosa Nursing1) Damage to tissue integrity related to mechanical tissue destruction secondary to pressure, friction and faction.2) Damage to physical mobility related to limitation of movement required, the status of which is conditioned, loss of motor control due to changes in mental status.3) Changes in nutrition less than body requirements related to inability of oral intake.4) High risk of infection associated with decubitus basic exposure, suppression of inflammatory responses.5) High risk for ineffective management of therapeutic regimen related to insufficient knowledge of the etiology, prevention, treatment and care at home.
3.Intervensi and Implementation1) Damage to tissue integrity related to mechanical tissue destruction secondary to pressure, friction and faction.- Apply principles of prevention of decubitus sores.R: the precautionary principle decubitus sores, covers reduce or rotate the pressure of the soft tissue.- Set posis patients as comfortable as possible.R: minimizing the occurrence of pressure sores affected tissue.- Wrap the wound with a bandage that retains moisture on the wound environment.R: moist wound healing can accelerate.
2) Damage to physical mobility related to limitation of movement required, the status of which is conditioned, loss of motor control due to changes in mental status.- Support the mobilization of a higher level.R: regular motion consistent relieving pressure on bone protrusions.- Assist / encourage self care / hygiene, such as bathing.R: increased muscle strength and circulation, increase patient control of health improvement in the situation and the environment.- Pay particular attention to the skin.R: research shows that skin is very susceptible to damage due to the weight concentration.
3) Changes in nutrition less than body requirements related to inability of oral intake.- Give preformance eat small amounts, often and in a warm state.R: help prevent gastric distension / discomfort and increase intake, increase appetite.- Help oral hygiene before meals.R: oral / clean equipment increased appetite good.- Maintain strict calorie.R: precise guidelines for the proper calorie intake.
4) High risk of infection associated with decubitus basic exposure, suppression of inflammatory responses.- Use the proper technique for changing a bandage.R: good technique reduces the entry of pathogenic microorganisms into the wound. Measure signs - vital signs.R: an increase in body temperature, tachycardia showed the presence of sepsis.- Use sterile gloves every bandage change.R: every ulcers contaminated by different microorganisms, these measures can prevent infection.- Wash the wound with 0.9% NaCl solution.R: Can get rid of dead tissue on the surface of the skin and reducing microorganisms.- Give the antibiotic medication as indicated.R: decubitus ulcers pilihanpada useful antibiotics against gram-negative organisms and gram positive.
5) High risk for ineffective management of therapeutic regimen related to insufficient knowledge of the etiology, prevention, treatment and care at home.- Encourage measures to prevent decubitus sores.R: injury prevention is easier than treatment of pressure sores.- Encourage measures to treat decubitus sores.R: This specific instructions to help patients and families learn to improve healing and prevent infection.
4. Evaluation1) Patients can prevent and identify factors causing decubitus sores; shows the progress of healing.2) patients had skin without neritema and not pale.3) The patient showed an increase in body weight and muscle mass.4) Leather will not teritasi due exposure to fecal or urine drainage.5) Demonstrate effective learning outcomes for the purpose of repatriation and patient care at home.
REFERENCESCapernito, Linda Juall. , 1999. Plans and Documentation Nursing Diagnosis: Nursing Diagnosis and Collaborative Problems Ed.2. Jakarta: EGC.Doenges, Marilynn E. In 2000. Nursing Plans: Guidelines for Planning and Documenting Patient Care. Jakarta: EGC.Nurachman, Elly. , 2001. Nutrition In Nursing. Jakarta: Sagung Seto.
ANEMIA
A. PengertianAnemia adalah gejala dari kondisi yang mendasari, seperti kehilangan komponen darah, elemen tak adekuat atau kurangnya nutrisi yang dibutuhkan untuk pembentukan sel darah merah, yang mengakibatkan penurunan kapasitas pengangkut oksigen darah (Doenges, 1999).
Anemia adalah istilah yang menunjukan rendahnya hitungan sel darah merah dan kadar hemoglobin dan hematokrit di bawah normal (Smeltzer, 2002 : 935).
Anemia adalah berkurangnya hingga di bawah nilai normal sel darah merah, kualitas hemoglobin dan volume packed red bloods cells (hematokrit) per 100 ml darah (Price, 2006 : 256).
Dengan demikian anemia bukan merupakan suatu diagnosis atau penyakit, melainkan merupakan pencerminan keadaan suatu penyakit atau gangguan fungsi tubuh dan perubahan patotisiologis yang mendasar yang diuraikan melalui anemnesis yang seksama, pemeriksaan fisik dan informasi laboratorium.
B. Etiologi
Penyebab tersering dari anemia adalah kekurangan zat gizi yang diperlukan untuk sintesis eritrosit, antara lain besi, vitamin B12 dan asam folat. Selebihnya merupakan akibat dari beragam kondisi seperti perdarahan, kelainan genetik, penyakit kronik, keracunan obat, dan sebagainya.
Penyebab umum dari anemia:
- Perdarahan hebat
- Akut (mendadak)
- Kecelakaan
- Pembedahan
- Persalinan
- Pecah pembuluh darah
- Penyakit Kronik (menahun)
- Perdarahan hidung
- Wasir (hemoroid)
- Ulkus peptikum
- Kanker atau polip di saluran pencernaan
- Tumor ginjal atau kandung kemih
- Perdarahan menstruasi yang sangat banyak
- Berkurangnya pembentukan sel darah merah
- Kekurangan zat besi
- Kekurangan vitamin B12
- Kekurangan asam folat
- Kekurangan vitamin C
- Penyakit kronik
- Meningkatnya penghancuran sel darah merah
- Pembesaran limpa
- Kerusakan mekanik pada sel darah merah
- Reaksi autoimun terhadap sel darah merah
- Hemoglobinuria nokturnal paroksismal
- Sferositosis herediter
- Elliptositosis herediter
- Kekurangan G6PD
- Penyakit sel sabit
- Penyakit hemoglobin C
- Penyakit hemoglobin S-C
- Penyakit hemoglobin E
- Thalasemia (Burton, 1990).
Timbulnya anemia mencerminkan adanya kegagalan sum-sum tulang atau kehilangan sel darah merah berlebihan atau keduanya. Kegagalan sum-sum tulang dapt terjadi akibat kekurangan nutrisi, pajanan toksik, inuasi tumor, atau kebanyakan akibat penyebab yang tidak diketahui. Sel darah merah dapat hilang melalui perdarahan atau hemolisis (destruksi) pada kasus yang disebut terakhir, masalah dapat akibat efek sel darah merah yang tidak sesuai dengan ketahanan sel darah merah normal atau akibat beberapa factor diluar sel darah merah yang menyebabkan destruksi sel darah merah.
Lisis sel darah merah (disolusi) terjadi terutama dalam system fagositik atau dalam system retikuloendotelial terutama dalam hati dan limpa. Sebagai hasil samping proses ini bilirubin yang sedang terbentuk dalam fagosit akan masuk dalam aliran darah. Setiap kenaikan destruksi sel darah merah (hemolisis) segera direpleksikan dengan meningkatkan bilirubin plasma (konsentrasi normalnya 1 mg/dl atau kurang ; kadar 1,5 mg/dl mengakibatkan ikterik pada sclera.
Anemia merupakan penyakit kurang darah yang ditandai rendahnya kadar hemoglobin (Hb) dan sel darah merah (eritrosit). Fungsi darah adalah membawa makanan dan oksigen ke seluruh organ tubuh. Jika suplai ini kurang, maka asupan oksigen pun akan kurang. Akibatnya dapat menghambat kerja organ-organ penting, Salah satunya otak. Otak terdiri dari 2,5 miliar sel bioneuron. Jika kapasitasnya kurang, maka otak akan seperti komputer yang memorinya lemah, Lambat menangkap. Dan kalau sudah rusak, tidak bisa diperbaiki (Sjaifoellah, 1998).
D. Manifestasi klinis
Gejala klinis yang muncul merefleksikan gangguan fungsi dari berbagai sistem dalam tubuh antara lain penurunan kinerja fisik, gangguan neurologik (syaraf) yang dimanifestasikan dalam perubahan perilaku, anorexia (badan kurus kerempeng), pica, serta perkembangan kognitif yang abnormal pada anak. Sering pula terjadi abnormalitas pertumbuhan, gangguan fungsi epitel, dan berkurangnya keasaman lambung. Cara mudah mengenal anemia dengan 5L, yakni lemah, letih, lesu, lelah, lalai. Kalau muncul 5 gejala ini, bisa dipastikan seseorang terkena anemia. Gejala lain adalah munculnya sklera (warna pucat pada bagian kelopak mata bawah).
Anemia bisa menyebabkan kelelahan, kelemahan, kurang tenaga dan kepala terasa melayang. Jika anemia bertambah berat, bisa menyebabkan stroke atau serangan jantung(Sjaifoellah, 1998).
E. Komplikasi
Anemia juga menyebabkan daya tahan tubuh berkurang. Akibatnya, penderita anemia akan mudah terkena infeksi. Gampang batuk-pilek, gampang flu, atau gampang terkena infeksi saluran napas, jantung juga menjadi gampang lelah, karena harus memompa darah lebih kuat. Pada kasus ibu hamil dengan anemia, jika lambat ditangani dan berkelanjutan dapat menyebabkan kematian, dan berisiko bagi janin. Selain bayi lahir dengan berat badan rendah, anemia bisa juga mengganggu perkembangan organ-organ tubuh, termasuk otak (Sjaifoellah, 1998).
F. Pemeriksaan penunjang
Jumlah darah lengkap (JDL) : hemoglobin dan hemalokrit menurun.
Jumlah eritrosit : menurun (AP), menurun berat (aplastik); MCV (molume korpuskular rerata) dan MCH (hemoglobin korpuskular rerata) menurun dan mikrositik dengan eritrosit hipokronik (DB), peningkatan (AP). Pansitopenia (aplastik).
Jumlah retikulosit : bervariasi, misal : menurun (AP), meningkat (respons sumsum tulang terhadap kehilangan darah/hemolisis).
Pewarna sel darah merah : mendeteksi perubahan warna dan bentuk (dapat mengindikasikan tipe khusus anemia).
LED : Peningkatan menunjukkan adanya reaksi inflamasi, misal : peningkatan kerusakan sel darah merah : atau penyakit malignasi.
Masa hidup sel darah merah : berguna dalam membedakan diagnosa anemia, misal : pada tipe anemia tertentu, sel darah merah mempunyai waktu hidup lebih pendek.
Tes kerapuhan eritrosit : menurun (DB).
SDP : jumlah sel total sama dengan sel darah merah (diferensial) mungkin meningkat (hemolitik) atau menurun (aplastik).
Jumlah trombosit : menurun caplastik; meningkat (DB); normal atau tinggi (hemolitik)
Hemoglobin elektroforesis : mengidentifikasi tipe struktur hemoglobin.
Bilirubin serum (tak terkonjugasi): meningkat (AP, hemolitik).
Folat serum dan vitamin B12 membantu mendiagnosa anemia sehubungan dengan defisiensi masukan/absorpsi
Besi serum : tak ada (DB); tinggi (hemolitik)
TBC serum : meningkat (DB)
Feritin serum : meningkat (DB)
Masa perdarahan : memanjang (aplastik)
LDH serum : menurun (DB)
Tes schilling : penurunan eksresi vitamin B12 urine (AP)
Guaiak : mungkin positif untuk darah pada urine, feses, dan isi gaster, menunjukkan perdarahan akut / kronis (DB).
Analisa gaster : penurunan sekresi dengan peningkatan pH dan tak adanya asam hidroklorik bebas (AP).
Aspirasi sumsum tulang/pemeriksaan/biopsi : sel mungkin tampak berubah dalam jumlah, ukuran, dan bentuk, membentuk, membedakan tipe anemia, misal: peningkatan megaloblas (AP), lemak sumsum dengan penurunan sel darah (aplastik).
Pemeriksaan andoskopik dan radiografik : memeriksa sisi perdarahan : perdarahan GI (Doenges, 1999).
G. Penatalaksanaan Medis
Tindakan umum :
Penatalaksanaan anemia ditunjukan untuk mencari penyebab dan mengganti darah yang hilang.
1. Transpalasi sel darah merah.
2. Antibiotik diberikan untuk mencegah infeksi.
3. Suplemen asam folat dapat merangsang pembentukan sel darah merah.
4. Menghindari situasi kekurangan oksigen atau aktivitas yang membutuhkan oksigen
5. Obati penyebab perdarahan abnormal bila ada.
6. Diet kaya besi yang mengandung daging dan sayuran hijau.
Pengobatan (untuk pengobatan tergantung dari penyebabnya) :
1. Anemia defisiensi besi
Penatalaksanaan :
Mengatur makanan yang mengandung zat besi, usahakan makanan yang diberikan seperti ikan, daging, telur dan sayur.
Pemberian preparat fe
Perrosulfat 3x 200mg/hari/per oral sehabis makan
Peroglukonat 3x 200 mg/hari /oral sehabis makan.
2. Anemia pernisiosa : pemberian vitamin B12
3. Anemia asam folat : asam folat 5 mg/hari/oral
4. Anemia karena perdarahan : mengatasi perdarahan dan syok dengan pemberian cairan dan transfusi darah.
MANAJEMEN KEPERAWATAN
A. Pengkajian
Pengkajian adalah langkah awal dan dasar dalam proses keperawatan secara menyeluru(Boedihartono, 1994).
Pengkajian pasien dengan anemia (Doenges, 1999) meliputi :
1) Aktivitas / istirahat
Gejala : keletihan, kelemahan, malaise umum. Kehilangan produktivitas ; penurunan semangat untuk bekerja. Toleransi terhadap latihan rendah. Kebutuhan untuk tidur dan istirahat lebih banyak.
Tanda : takikardia/ takipnae ; dispnea pada waktu bekerja atau istirahat. Letargi, menarik diri, apatis, lesu, dan kurang tertarik pada sekitarnya. Kelemahan otot, dan penurunan kekuatan. Ataksia, tubuh tidak tegak. Bahu menurun, postur lunglai, berjalan lambat, dan tanda-tanda lain yang menunujukkan keletihan.
2) Sirkulasi
Gejala : riwayat kehilangan darah kronik, misalnya perdarahan GI kronis, menstruasi berat (DB), angina, CHF (akibat kerja jantung berlebihan). Riwayat endokarditis infektif kronis. Palpitasi (takikardia kompensasi).
Tanda : TD : peningkatan sistolik dengan diastolik stabil dan tekanan nadi melebar, hipotensi postural. Disritmia : abnormalitas EKG, depresi segmen ST dan pendataran atau depresi gelombang T; takikardia. Bunyi jantung : murmur sistolik (DB). Ekstremitas (warna) : pucat pada kulit dan membrane mukosa (konjuntiva, mulut, faring, bibir) dan dasar kuku. (catatan: pada pasien kulit hitam, pucat dapat tampak sebagai keabu-abuan). Kulit seperti berlilin, pucat (aplastik, AP) atau kuning lemon terang (AP). Sklera : biru atau putih seperti mutiara (DB). Pengisian kapiler melambat (penurunan aliran darah ke kapiler dan vasokontriksi kompensasi) kuku : mudah patah, berbentuk seperti sendok (koilonikia) (DB). Rambut : kering, mudah putus, menipis, tumbuh uban secara premature (AP).
3) Integritas ego
Gejala : keyakinanan agama/budaya mempengaruhi pilihan pengobatan, misalnya penolakan transfusi darah.
Tanda : depresi.
4) Eleminasi
Gejala : riwayat pielonefritis, gagal ginjal. Flatulen, sindrom malabsorpsi (DB). Hematemesis, feses dengan darah segar, melena. Diare atau konstipasi. Penurunan haluaran urine.
Tanda : distensi abdomen.
5) Makanan/cairan
Gejala : penurunan masukan diet, masukan diet protein hewani rendah/masukan produk sereal tinggi (DB). Nyeri mulut atau lidah, kesulitan menelan (ulkus pada faring). Mual/muntah, dyspepsia, anoreksia. Adanya penurunan berat badan. Tidak pernah puas mengunyah atau peka terhadap es, kotoran, tepung jagung, cat, tanah liat, dan sebagainya (DB).
Tanda : lidah tampak merah daging/halus (AP; defisiensi asam folat dan vitamin B12). Membrane mukosa kering, pucat. Turgor kulit : buruk, kering, tampak kisut/hilang elastisitas (DB). Stomatitis dan glositis (status defisiensi). Bibir : selitis, misalnya inflamasi bibir dengan sudut mulut pecah. (DB).
6) Neurosensori
Gejala : sakit kepala, berdenyut, pusing, vertigo, tinnitus, ketidak mampuan berkonsentrasi. Insomnia, penurunan penglihatan, dan bayangan pada mata. Kelemahan, keseimbangan buruk, kaki goyah ; parestesia tangan/kaki (AP) ; klaudikasi. Sensasi manjadi dingin.
Tanda : peka rangsang, gelisah, depresi cenderung tidur, apatis. Mental : tak mampu berespons, lambat dan dangkal. Oftalmik : hemoragis retina (aplastik, AP). Epitaksis : perdarahan dari lubang-lubang (aplastik). Gangguan koordinasi, ataksia, penurunan rasa getar, dan posisi, tanda Romberg positif, paralysis (AP).
7) Nyeri/kenyamanan
Gejala : nyeri abdomen samara : sakit kepala (DB)
8) Pernapasan
Gejala : riwayat TB, abses paru. Napas pendek pada istirahat dan aktivitas.
Tanda : takipnea, ortopnea, dan dispnea.
9) Keamanan
Gejala : riwayat pekerjaan terpajan terhadap bahan kimia,. Riwayat terpajan pada radiasi; baik terhadap pengobatan atau kecelekaan. Riwayat kanker, terapi kanker. Tidak toleran terhadap dingin dan panas. Transfusi darah sebelumnya. Gangguan penglihatan, penyembuhan luka buruk, sering infeksi.
Tanda : demam rendah, menggigil, berkeringat malam, limfadenopati umum. Ptekie dan ekimosis (aplastik).
10) Seksualitas
Gejala : perubahan aliran menstruasi, misalnya menoragia atau amenore (DB). Hilang libido (pria dan wanita). Imppoten.
Tanda : serviks dan dinding vagina pucat.
B. Diagnosa Keperawatan
Diagnosa keperawatan adalah suatu penyatuan dari masalah pasien yang nyata maupun potensial berdasarkan data yang telah dikumpulkan (Boedihartono, 1994).
Diagnosa keperawatan yang muncul pada pasien dengan anemia (Doenges, 1999) meliputi :
1. Risiko tinggi terhadap infeksi berhubungan dengan tidak adekuatnya pertahanan sekunder (penurunan hemoglobin leucopenia, atau penurunan granulosit (respons inflamasi tertekan)).
2. Perubahan nutrisi kurang dari kebutuhan tubuh berhubungan dengan kegagalan untuk mencerna atau ketidak mampuan mencerna makanan /absorpsi nutrient yang diperlukan untuk pembentukan sel darah merah.
3. Intoleransi aktivitas berhubungan dengan ketidakseimbangan antara suplai oksigen (pengiriman) dan kebutuhan.
4. Perubahan perfusi jaringan berhubungan dengan penurunan komponen seluler yang diperlukan untuk pengiriman oksigen/nutrient ke sel.
5. Risiko tinggi terhadap kerusakan integritas kulit berhubungan dengan perubahan sirkulasi dan neurologist.
6. Konstipasi atau Diare berhubungan dengan penurunan masukan diet; perubahan proses pencernaan; efek samping terapi obat.
7. Kurang pengetahuan sehubungan dengan kurang terpajan/mengingat ; salah interpretasi informasi ; tidak mengenal sumber informasi.
C. Intervensi/Implementasi keperawatan
Intervensi adalah penyusunan rencana tindakan keperawatan yang akan dilaksanakan untuk menanggulangi masalah sesuai dengan diagnosa keperawatan (Boedihartono, 1994)
Implementasi adalah pengelolaan dan perwujudan dari rencana keperawatan yang telah disusun pada tahap perencanaan (Effendi, 1995).
Intervensi dan implementasi keperawatan pasien dengan anemia (Doenges, 1999) adalah :
1) Risiko tinggi terhadap infeksi berhubungan dengan tidak adekuatnya pertahanan sekunder (penurunan hemoglobin leucopenia, atau penurunan granulosit (respons inflamasi tertekan)).
Tujuan : Infeksi tidak terjadi.
Kriteria hasil : - mengidentifikasi perilaku untuk mencegah/menurunkan risiko infeksi.
- meningkatkan penyembuhan luka, bebas drainase purulen atau eritema, dan demam.
INTERVENSI & IMPLEMENTASI
Tingkatkan cuci tangan yang baik ; oleh pemberi perawatan dan pasien.
Rasional : mencegah kontaminasi silang/kolonisasi bacterial. Catatan : pasien dengan anemia berat/aplastik dapat berisiko akibat flora normal kulit.
Pertahankan teknik aseptic ketat pada prosedur/perawatan luka.
Rasional : menurunkan risiko kolonisasi/infeksi bakteri.
Berikan perawatan kulit, perianal dan oral dengan cermat.
Rasional : menurunkan risiko kerusakan kulit/jaringan dan infeksi.
Motivasi perubahan posisi/ambulasi yang sering, latihan batuk dan napas dalam.
Rasional : meningkatkan ventilasi semua segmen paru dan membantu memobilisasi sekresi untuk mencegah pneumonia.
Tingkatkan masukkan cairan adekuat.
Rasional : membantu dalam pengenceran secret pernapasan untuk mempermudah pengeluaran dan mencegah stasis cairan tubuh misalnya pernapasan dan ginjal.
Pantau/batasi pengunjung. Berikan isolasi bila memungkinkan.
Rasional : membatasi pemajanan pada bakteri/infeksi. Perlindungan isolasi dibutuhkan pada anemia aplastik, bila respons imun sangat terganggu.
Pantau suhu tubuh. Catat adanya menggigil dan takikardia dengan atau tanpa demam.
Rasional : adanya proses inflamasi/infeksi membutuhkan evaluasi/pengobatan.
Amati eritema/cairan luka.
Rasional : indikator infeksi lokal. Catatan : pembentukan pus mungkin tidak ada bila granulosit tertekan.
Ambil specimen untuk kultur/sensitivitas sesuai indikasi (kolaborasi)
Rasional : membedakan adanya infeksi, mengidentifikasi pathogen khusus dan mempengaruhi pilihan pengobatan.
Berikan antiseptic topical ; antibiotic sistemik (kolaborasi).
Rasional : mungkin digunakan secara propilaktik untuk menurunkan kolonisasi atau untuk pengobatan proses infeksi local.
2) Perubahan nutrisi kurang dari kebutuhan tubuh berhubungan dengan kegagalan untuk mencerna atau ketidak mampuan mencerna makanan /absorpsi nutrient yang diperlukan untuk pembentukan sel darah merah.
Tujuan : kebutuhan nutrisi terpenuhi
Kriteria hasil : - menunujukkan peningkatan/mempertahankan berat badan dengan nilai laboratorium normal.
- tidak mengalami tanda mal nutrisi.
- Menununjukkan perilaku, perubahan pola hidup untuk meningkatkan dan atau mempertahankan berat badan yang sesuai.
INTERVENSI & IMPLEMENTASI
Kaji riwayat nutrisi, termasuk makan yang disukai.
Rasional : mengidentifikasi defisiensi, memudahkan intervensi.
Observasi dan catat masukkan makanan pasien.
Rasional : mengawasi masukkan kalori atau kualitas kekurangan konsumsi makanan.
Timbang berat badan setiap hari.
Rasional : mengawasi penurunan berat badan atau efektivitas intervensi nutrisi.
Berikan makan sedikit dengan frekuensi sering dan atau makan diantara waktu makan.
Rasional : menurunkan kelemahan, meningkatkan pemasukkan dan mencegah distensi gaster.
Observasi dan catat kejadian mual/muntah, flatus dan dan gejala lain yang berhubungan.
Rasional : gejala GI dapat menunjukkan efek anemia (hipoksia) pada organ.
Berikan dan Bantu hygiene mulut yang baik ; sebelum dan sesudah makan, gunakan sikat gigi halus untuk penyikatan yang lembut. Berikan pencuci mulut yang di encerkan bila mukosa oral luka.
Rasional : meningkatkan nafsu makan dan pemasukkan oral. Menurunkan pertumbuhan bakteri, meminimalkan kemungkinan infeksi. Teknik perawatan mulut khusus mungkin diperlukan bila jaringan rapuh/luka/perdarahan dan nyeri berat.
Kolaborasi pada ahli gizi untuk rencana diet.
Rasional : membantu dalam rencana diet untuk memenuhi kebutuhan individual.
Kolaborasi ; pantau hasil pemeriksaan laboraturium.
Rasional : meningkatakan efektivitas program pengobatan, termasuk sumber diet nutrisi yang dibutuhkan.
Kolaborasi ; berikan obat sesuai indikasi.
Rasional : kebutuhan penggantian tergantung pada tipe anemia dan atau adanyan masukkan oral yang buruk dan defisiensi yang diidentifikasi.
3) Intoleransi aktivitas berhubungan dengan ketidakseimbangan antara suplai oksigen (pengiriman) dan kebutuhan.
Tujuan : dapat mempertahankan/meningkatkan ambulasi/aktivitas.
Kriteria hasil : - melaporkan peningkatan toleransi aktivitas (termasuk aktivitas sehari-hari)
- menunjukkan penurunan tanda intolerasi fisiologis, misalnya nadi, pernapasan, dan tekanan darah masih dalam rentang normal.
INTERVENSI & IMPLEMENTASI
Kaji kemampuan ADL pasien.
Rasional : mempengaruhi pilihan intervensi/bantuan.
Kaji kehilangan atau gangguan keseimbangan, gaya jalan dan kelemahan otot.
Rasional : menunjukkan perubahan neurology karena defisiensi vitamin B12 mempengaruhi keamanan pasien/risiko cedera.
Observasi tanda-tanda vital sebelum dan sesudah aktivitas.
Rasional : manifestasi kardiopulmonal dari upaya jantung dan paru untuk membawa jumlah oksigen adekuat ke jaringan.
Berikan lingkungan tenang, batasi pengunjung, dan kurangi suara bising, pertahankan tirah baring bila di indikasikan.
Rasional : meningkatkan istirahat untuk menurunkan kebutuhan oksigen tubuh dan menurunkan regangan jantung dan paru.
Gunakan teknik menghemat energi, anjurkan pasien istirahat bila terjadi kelelahan dan kelemahan, anjurkan pasien melakukan aktivitas semampunya (tanpa memaksakan diri).
Rasional : meningkatkan aktivitas secara bertahap sampai normal dan memperbaiki tonus otot/stamina tanpa kelemahan. Meingkatkan harga diri dan rasa terkontrol.
4) Perubahan perfusi jaringan berhubungan dengan penurunan komponen seluler yang diperlukan untuk pengiriman oksigen/nutrient ke sel.
Tujuan : peningkatan perfusi jaringan
Kriteria hasil : - menunjukkan perfusi adekuat, misalnya tanda vital stabil.
INTERVENSI & IMPLEMENTASI
Awasi tanda vital kaji pengisian kapiler, warna kulit/membrane mukosa, dasar kuku.
Rasional : memberikan informasi tentang derajat/keadekuatan perfusi jaringan dan membantu menetukan kebutuhan intervensi.
Tinggikan kepala tempat tidur sesuai toleransi.
Rasional : meningkatkan ekspansi paru dan memaksimalkan oksigenasi untuk kebutuhan seluler. Catatan : kontraindikasi bila ada hipotensi.
Awasi upaya pernapasan ; auskultasi bunyi napas perhatikan bunyi adventisius.
Rasional : dispnea, gemericik menununjukkan gangguan jajntung karena regangan jantung lama/peningkatan kompensasi curah jantung.
Selidiki keluhan nyeri dada/palpitasi.
Rasional : iskemia seluler mempengaruhi jaringan miokardial/ potensial risiko infark.
Hindari penggunaan botol penghangat atau botol air panas. Ukur suhu air mandi dengan thermometer.
Rasional : termoreseptor jaringan dermal dangkal karena gangguan oksigen.
Kolaborasi pengawasan hasil pemeriksaan laboraturium. Berikan sel darah merah lengkap/packed produk darah sesuai indikasi.
Rasional : mengidentifikasi defisiensi dan kebutuhan pengobatan /respons terhadap terapi.
Berikan oksigen tambahan sesuai indikasi.
Rasional : memaksimalkan transport oksigen ke jaringan.
5) Risiko tinggi terhadap kerusakan integritas kulit berhubungan dengan perubahan sirkulasi dan neurologist.
Tujuan : dapat mempertahankan integritas kulit.
Kriteria hasil : - mengidentifikasi factor risiko/perilaku individu untuk mencegah cedera dermal.
INTERVENSI & IMPLEMENTASI
Kaji integritas kulit, catat perubahan pada turgor, gangguan warna, hangat local, eritema, ekskoriasi.
Rasional : kondisi kulit dipengaruhi oleh sirkulasi, nutrisi dan imobilisasi. Jaringan dapat menjadi rapuh dan cenderung untuk infeksi dan rusak.
Reposisi secara periodic dan pijat permukaan tulang apabila pasien tidak bergerak atau ditempat tidur.
Rasional : meningkatkan sirkulasi kesemua kulit, membatasi iskemia jaringan/mempengaruhi hipoksia seluler.
Anjurkan pemukaan kulit kering dan bersih. Batasi penggunaan sabun.
Rasional : area lembab, terkontaminasi, memberikan media yang sangat baik untuk pertumbuhan organisme patogenik. Sabun dapat mengeringkan kulit secara berlebihan.
Bantu untuk latihan rentang gerak.
Rasional : meningkatkan sirkulasi jaringan, mencegah stasis.
Gunakan alat pelindung, misalnya kulit domba, keranjang, kasur tekanan udara/air. Pelindung tumit/siku dan bantal sesuai indikasi. (kolaborasi)
Rasional : menghindari kerusakan kulit dengan mencegah /menurunkan tekanan terhadap permukaan kulit.
6) Konstipasi atau Diare berhubungan dengan penurunan masukan diet; perubahan proses pencernaan; efek samping terapi obat.
Tujuan : membuat/kembali pola normal dari fungsi usus.
Kriteria hasil : - menunjukkan perubahan perilaku/pola hidup, yang diperlukan sebagai penyebab, factor pemberat.
INTERVENSI & IMPLEMENTASI
Observasi warna feses, konsistensi, frekuensi dan jumlah.
Rasional : membantu mengidentifikasi penyebab /factor pemberat dan intervensi yang tepat.
Auskultasi bunyi usus.
Rasional : bunyi usus secara umum meningkat pada diare dan menurun pada konstipasi.
Awasi intake dan output (makanan dan cairan).
Rasional : dapat mengidentifikasi dehidrasi, kehilangan berlebihan atau alat dalam mengidentifikasi defisiensi diet.
Dorong masukkan cairan 2500-3000 ml/hari dalam toleransi jantung.
Rasional : membantu dalam memperbaiki konsistensi feses bila konstipasi. Akan membantu memperthankan status hidrasi pada diare.
Hindari makanan yang membentuk gas.
Rasional : menurunkan distress gastric dan distensi abdomen
Kaji kondisi kulit perianal dengan sering, catat perubahan kondisi kulit atau mulai kerusakan. Lakukan perawatan perianal setiap defekasi bila terjadi diare.
Rasional : mencegah ekskoriasi kulit dan kerusakan.
Kolaborasi ahli gizi untuk diet siembang dengan tinggi serat dan bulk.
Rasional : serat menahan enzim pencernaan dan mengabsorpsi air dalam alirannya sepanjang traktus intestinal dan dengan demikian menghasilkan bulk, yang bekerja sebagai perangsang untuk defekasi.
Berikan pelembek feses, stimulant ringan, laksatif pembentuk bulk atau enema sesuai indikasi. Pantau keefektifan. (kolaborasi)
Rasional : mempermudah defekasi bila konstipasi terjadi.
Berikan obat antidiare, misalnya Defenoxilat Hidroklorida dengan atropine (Lomotil) dan obat mengabsorpsi air, misalnya Metamucil. (kolaborasi).
Rasional : menurunkan motilitas usus bila diare terjadi.
7) Kurang pengetahuan sehubungan dengan kurang terpajan/mengingat ; salah interpretasi informasi ; tidak mengenal sumber informasi.
Tujuan : pasien mengerti dan memahami tentang penyakit, prosedur diagnostic dan rencana pengobatan.
Kriteria hasil : - pasien menyatakan pemahamannya proses penyakit dan penatalaksanaan penyakit.
- mengidentifikasi factor penyebab.
- Melakukan tiindakan yang perlu/perubahan pola hidup.
INTERVENSI & IMPLEMENTASI
Berikan informasi tentang anemia spesifik. Diskusikan kenyataan bahwa terapi tergantung pada tipe dan beratnya anemia.
Rasional : memberikan dasar pengetahuan sehingga pasien dapat membuat pilihan yang tepat. Menurunkan ansietas dan dapat meningkatkan kerjasama dalam program terapi.
Tinjau tujuan dan persiapan untuk pemeriksaan diagnostic.
Rasional : ansietas/ketakutan tentang ketidaktahuan meningkatkan stress, selanjutnya meningkatkan beban jantung. Pengetahuan menurunkan ansietas.
Kaji tingkat pengetahuan klien dan keluarga tentang penyakitnya.
Rasional : megetahui seberapa jauh pengalaman dan pengetahuan klien dan keluarga tentang penyakitnya.
Berikan penjelasan pada klien tentang penyakitnya dan kondisinya sekarang.
Rasional : dengan mengetahui penyakit dan kondisinya sekarang, klien dan keluarganya akan merasa tenang dan mengurangi rasa cemas.
Anjurkan klien dan keluarga untuk memperhatikan diet makanan nya.
Rasional : diet dan pola makan yang tepat membantu proses penyembuhan.
Minta klien dan keluarga mengulangi kembali tentang materi yang telah diberikan.
Rasional : mengetahui seberapa jauh pemahaman klien dan keluarga serta menilai keberhasilan dari tindakan yang dilakukan.
D. Evaluasi
Evaluasi adalah perbandingan yang sistemik atau terencana tentang kesehatan pasien dengan tujuan yang telah ditetapkan, dilakukan dengan cara berkesinambungan, dengan melibatkan pasien, keluarga dan tenaga kesehatan lainnya. (Lynda Juall Capenito, 1999:28)
Evaluasi pada pasien dengan anemia adalah :
1) Infeksi tidak terjadi.
2) Kebutuhan nutrisi terpenuhi.
3) Pasien dapat mempertahankan/meningkatkan ambulasi/aktivitas.
4) Peningkatan perfusi jaringan.
5) Dapat mempertahankan integritas kulit.
6) Membuat/kembali pola normal dari fungsi usus.
7) Pasien mengerti dan memahami tentang penyakit, prosedur diagnostic dan rencana pengobatan.
DAFTAR PUSTAKA
- Boedihartono. 1994. Proses Keperawatan di Rumah Sakit. Jakarta.
- Burton, J.L. 1990. Segi Praktis Ilmu Penyakit Dalam. Binarupa Aksara : Jakarta
- Carpenito, L. J. 1999. Rencana Asuhan keperawatan dan dokumentasi keperawatan, Diagnosis Keperawatan dan Masalah Kolaboratif, ed. 2. EGC : Jakarta
- Doenges, Marilynn E. 1999. Rencana Asuhan Keperawatan pedoman untuk perencanaan dan pendokumentasian pasien. ed.3. EGC : Jakarta
- Effendi , Nasrul. 1995. Pengantar Proses Keperawatan. EGC : Jakarta.
- Hassa. 1985. Ilmu Kesehatan Anak jilid 1. FKUI : Jakarta
- http://id.wikipedia.org/wiki/Anemia
- http://www.kompas.com/ver1/Kesehatan/0611/30/104458.htm
- Noer, Sjaifoellah. 1998. Standar Perawatan Pasien. Monica Ester : Jakarta.
- Wilkinson, Judith M. 2006. Buku Saku Diagnosis Keperawatan, edisi 7. EGC : Jakarta.
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