ASKEP LEUKIMIA

MAKALAH KEPERAWATAN KLINIK VI (KEPERAWATAN MEDIKAL BEDAH)

ASUHAN KEPERAWA KEPERAWATAN KLIEN DENGAN LEUKEMIA

Disusun Oleh Kelompok 18 DESNI TRI UTAMI SYAFRIDA SYAFRIDA HANUM TRI JULIANSYAH UMMAMI ANESA INDRI

Dosen !em"im"in#$ Yesi Yesi H%sneli N& S'Kp'& MNS

PROGRAM STUDI ILMU KEPERAWATAN UNIVERSITAS RIAU PEKANBARU 2012

1

KATA PENGANTAR  PENG ANTAR 

Se#%l% pu(i "%#i All%h S)T *%n# +el%h mem"e,ik%n kesemp%+%n kep%-% penulis un+uk  -%p%+ mem"e,ik%n se"u%h m%k%l%h *%n# "e,(u-ul .Asuh%n Kepe,%/%+%n !%-% Klien Den#%n Leuk Leukem emi%0 i%0'' Ti-%k i-%k lup% lup% pul% pul% sh%l% sh%l%/% /%++ "e,i "e,i,i ,in# n# s%l%m s%l%m penu penuli liss u%p u%pk% k%n n kep% kep%-% -% N%"i N%"i Muh%mm%- SA) *%n# +el%h mem"%/% um%+ m%nusi% -%,i %l%m ke"o-oh%n menu(u %l%m *%n# penuh +eknolo#i *%n# +el%h ki+% ,%s%k%n s%mp%i p%-% s%%+ ini' !%-% !%-% kesemp kesemp%+%n %+%n k%li k%li ini penuli penuliss (u#% (u#% in#in in#in men*%m men*%mp%ik p%ik%n %n u%p%n u%p%n +e,im% +e,im% k%sih k%sih kep%-% kep%-% i"u Yesi Yesi H%sneli& H%sneli& N& S'Kp'& S'Kp'& MNS sel%ku sel%ku -osen -osen pem"im pem"im"in "in# # p%-% p%-% m%+% kuli%h kuli%h Kepe,%/%+%n Klinik I *%n# +el%h mem"e,ik%n -ukun#%n se,+% mo+i2%si' Semo#% mo+i2%si se,+% -ukun#%n *%n# I"u "e,ik%n -%p%+ men(%-i p%h%l% -i sisi sis i All%h S)T' S)T' D%l%m pen*eles%i%n m%k%l%h ini& penulis men*%-%,i "%h/% m%sih "%n*%k +e,-%p%+ keku keku,% ,%n# n#%n %n'' N%mu N%mun n -emik -emiki%n i%n&& penu penuli liss +el%h +el%h "e,u "e,us%h s%h%% sem%k sem%ksim sim%l %l mun# mun#ki kin n -en# -en#%n %n kem%mpu%n *%n# penulis miliki' Un+uk i+u& penulis (u#% men#h%,%pk%n k,i+ik -%n s%,%n *%n# mem"%n#un %#%, m%k%l%h ini -%p%+ le"ih "e,m%n3%%+ "%#i p%,% pem"%%'

!ek%n"%,u& 45 Ok+o"e, 4614

Tim !enulis

4

DAFTAR ISI  

Halaman

' ''''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' ''''' '''''' ''''' KATA PENGANTAR ''''

i

'''''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' ''''' '''''' '''''' ''' DAFTAR ISI''''

ii

BAB I PENDAHULUAN

1'1 1'1 L%+%, L%+%, 7el% 7el%k% k%n# n#'' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' ''''' '''''' '''''' '''''' ''''' ''''

1

1'4 1'4 Rumu Rumus%n s%n M%s% M%s%l% l%h' h''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' ''''' '''''' '''''' ''''' ''

4

1' 1' Tu(u% u(u%n' n''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' ''''' '''''' '''''' '''''' '''''' ''''' ''''' '''''' ''''' '''' ''

4

BAB II TINJAUAN TEORI

4'1 4'1 De3i De3ini nisi si'' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' ''''' '''''' '''''' '''



4'4 4'4 E+io E+iolo lo#i #i'' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' ''''' '''''' '''''' '''

9

4' 4' M%ni3es M%ni3es+%s +%sii Klinik Klinik'' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' ''''' '''''' '''''' '''''

8

4': 4': E2% E2%lu lu%si %si Di%# Di%#no nos+ s+ik ik'' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' ''''' '''''' '''''' '''''' ''''' ''''' '''''' ''''' ''''' ''''' ''

16

4'; Web Of Caution'' Caution'''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' ''''' '''''' '''''' '''''' '''

11

4'5 4'5 !en% !en%+% +%l%k l%ks% s%n% n%%n %n Me-i Me-is' s''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' ''''' '''''' '''''' '''''' '''''' ''''' ''''' '''''' '''

14

4'9 4'9 !en% !en%+% +%l%k l%ks% s%n% n%%n %n Kepe Kepe,% ,%/% /%+%n +%n'' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' ''''' '''''' '''''' '''''' ''''' ''''' '''''' '''''

1:

BAB III TINJAUAN KASUS

'1U '1U,%i ,%i%n %n K%su K%sus' s''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' ''''' ''''' ''''' '''

4

'4 '4 !en# !en#k% k%(i (i%n %n '''' '''''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' ''''' '''''' '''''

4

' ' An%li n%lis% s% D%+% D%+%'' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' ''''' '''''' '''''' '''''' ''''' ''''

4:

': ': Asuh% suh%n n Kepe Kepe,% ,%/% /%+%n +%n'' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' ''''' '''''' '''''' ''''' ''''' '''''' ''''' ''''' '''''' ''''' ''

49

'; Web Of Caution K%su K%sus' s''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' ''

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'5' '5' !en% !en%+% +%l% l%ks ks%n %n%% %%n n F%, F%,m m%kol %kolo# o#ii D%n D%n Non Non F%, F%,m% m%ko kolo lo#i #i'' '''' '''' '''' '''' '''' '''' '''' ''

6

'9 '9 Tu(u% u(u%n n !em" !em"el el%(% %(%,%n ,%n'' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' '''' ''''' '''''

1

DAFTAR PUSTAKA



BAB I PENDAHULUAN

11 La!a" La!a" B#la$an% B#la$an% Leukemi% me,up%k%n k%nke, *%n# +e,(%-i p%-% sel -%,%h m%nusi%' Un+uk men#e+%hui

+en+%n# leukemi%& ki+% h%,us men#en%l -%hulu sel=sel -%,%h *%n# no,m%l se,+% %p% *%n# +e,(%-i (ik% +e,ken% leukemi%' D%,%h m%nusi% +e,-i,i -%,i %i,%n *%n# -ise"u+ se"%#%i pl%sm% -%,%h& -%n +i#% kelompok sel -%,%h' Kelompok sel -%,%h i+u -i"e-%k%n men(%-i sel -%,%h me,%h& sel -%,%h pu+ih& -%n kepin#=kepin# -%,%h' Sel=sel -%,%h +e,se"u+ -i"u%+ -i sumsum +ul%n +ul%n#& #& -i ,u%n ,u%n# # me-u me-ul% l% +ul% +ul%n# n#'' !,os !,oses es pem"en pem"en+u +uk% k%n n sel=s sel=sel el -%,% -%,%h h -ise" -ise"u+ u+ -en# -en#%n %n hem%+opoiesis' O,%n# O,%n# -e/%s% -e/%s% memilik memilikii sumsum sumsum *%n# *%n# -i#un% -i#un%k%n k%n un+uk un+uk pem"en pem"en+uk +uk%n %n sel "e,up% "e,up% sumsum +ul%n# me,%h *%n# +e,"%+%s p%-% +ul%n# %n##o+% +u"uh -%n +en#ko,%k' Meskipun -ise"u+ sumsum +ul%n# me,%h& +emp%+ +e,se"u+ mem"u%+ sel -%,%h me,%h m%upun sel -%,%h  pu+ih' Sumsum -i +ul%n# %n##o+% "%-%n& +ul%n#=+ul%n# p%n(%n# -%,i +u"uh& %-%l%h -%l%m  "en+uk sumsum lem%k kunin#& *%n# me,up%k%n %-%n#%n -%n +i-%k %k+i3 "e,hu"un#%n -en#%n -en#%n pem"u%+%n pem"u%+%n sel=sel -%,%h' Ak%n Ak%n +e+%pi& -%p%+ "e,u"%h men(%-i sumsum +ul%n# me,%h  "il%m%n% +e,-%p%+ keku,%n#%n -%,%h >?,een& 466<@' Sumsum Sumsum +ul%n# +ul%n# men#%n men#%n-u -un# n# sel s+em s+em p,imi+i p,imi+i33 *%n# *%n# memili memiliki ki kem%mp kem%mpu%n u%n un+uk  un+uk   "e,eplik%si& "e,p,oli3e,%si& -%n "e,-i3e,ensi%si' !em"el%h%n #%,is ke+u,un%n *%n# pe,+%m% -%,i sel ini *%i+u sel m*eloi- -%n sel lim3oi-' Sel m*eloi- men#h%silk%n e,i+,osi+& m*elo"l%s+& -%n pl%+ele+ mel%lui p,eku,so,' M*elo"l%s+ p%-% sel m*eloi- kem"%li men#h%silk%n neu+,o3il&  "%so3il& -%n eosino3il *%n# "e,#,%nul%& se,+% monosi+ *%n# +i-%k "e,#,%nul%' Se-%n#k%n sel lim3oi- men#h%silk%n lim3o"l%s *%n# memp,o-uksi lim3osi+ T& lim3osi+ 7& -%n  Natural Killer ' Sel -%,%h pu+ih& +e,-i,i -%,i m*elo"l%s+ -%n lim3o"l%s se"%#%i pe,+%h%n%n +u"uh +e,h%-%p se,%n#%n "en-% %sin# >?ol-smi+h& 4614@' Sel -%,%h pu+ih %+%u leukosi+ "e,3un#si un+uk melin-un#i +u"uh +e,h%-%p in3eksi %+%u se,%n#% se,%n#%n n pen*%ki pen*%ki++ l%inn*% l%inn*%'' Sel -%,%h -%,%h me,%h me,%h %+%u e,i+,os e,i+,osi+ i+ "e,3un "e,3un#si #si un+uk un+uk men#%n men#%n#ku #ku++ oksi#en -%,i p%,u=p%,u ke selu,uh (%,in#%n +u"uh& -%n mem"%/% k%,"on-ioksi-% -%,i (% ,in#%n +u"uh kem"%li ke p%,u=p%,u' Kepin#=kepin# -%,%h %+%u +,om"osi+ s%n#%+ "e,pe,%n -%l%m  p,oses pem"eku%n -%,%h' Ke+ik% +e,(%-i leukemi%& +u"uh %k%n memp,o-uksi sel=sel -%,%h *%n# *%n# %"no,m %"no,m%l %l -%n -%l%m (uml%h (uml%h *%n# *%n# "es%,' "es%,' !%-% leukem leukemi%& i%& sel -%,%h -%,%h *%n# *%n# %"no,m %"no,m%l %l +e,se"u+ %-%l%h kelompok sel -%,%h pu+ih' Sel=sel -%,%h *%n# +e,ken% leukemi% %k%n s%n#%+  "e,"e-% -en#%n sel -%,%h no,m%l& -%n +i-%k m%mpu "e,3un#si sepe,+i l%*%kn*% sel -%,%h no,m%l' :

Leuk Leukem emi% i% me,u me,up% p%k%n k%n 4&8 4&8 -%,i -%,i selu selu,u ,uh h k%su k%suss k%nk k%nke, e,&& "elu "elum m %-% %-% %n#k %n#k%% p%s+ p%s+ii men#en%i insi-en leukemi% -i In-onesi%' Leukemi% +e,"%#i men(%-i -u% +ipe *%i+u leukemi% %ku+ -%n leukemi% k,onik' Leukemi% %ku+ +e,"%#i l%#i men(%-i Leukemi% Mielo"l%s+ik Aku+ >LMA@ -%n Leukemi% Lim3osi+ik Aku+ >LLA@' Di Ne#%,% m%(u sepe,+i Ame,ik% Se,ik%+& LMA me,up%k%n 4 -%,i selu,uh k%sus leukemi%' !en*%ki+ ini le"ih se,in# -i+emuk%n p%-% -e/%s% >8;@ -%,i p%-% %n%k >1;@' Insi-en LMA p%-% o,%n# *%n# "e,usi% 6 +%hun %-%l%h 6&8& p%-% o,%n# *%n# "e,usi% ;6 +%hun 4&9& se-%n#k%n p%-% o,%n# *%n# "e,usi% -i %+%s 5; +%hun %-%l%h se"es%, 1&9' LLA le"ih "%n*%k men*e,%n# p%-% %n%k=%n%k -en#%n pun%k usi% =; +%hun' Insi-en LLA %-%l%h 1B56'666 o,%n# pe, +%hun& -en#%n 9; p%sien "e,usi% ku,%n# -%,i 1; +%hun' Leukemi% k,onik +e,"%#i men(%-i -u% *%i+u Leukemi% M*eloi- K,onik >LMK@ -%n Leukemi% Lim3osi+ik K,onik >LLK@' Ke(%-i%n LMK men%p%i 46 -%,i semu% leukemi% p%-% -e/%s%' !%-% umumn*%& LMK men*e,%n# usi% :6=;6 +%hun& /%l%upun -%p%+ -i+emuk%n p%-% usi% mu-% -%n "i%s%n*% le"ih p,o#,esi3' Di Jep%n#& ke(%-i%nn*% menin#k%+ se+el%h pe,is+i/% "om %+om -i N%#%s%ki -%n Hi,oshim%& -emiki%n (u#% -i Rusi% se+el%h ,e%k+o, %+om Che,no"il mele-%k' LLK -i Ne#%,% 7%,%+ memiliki %n#k% ke(%-i%n B166'666' Usi% ,e,%+% p%sien s%%+ -i%#nosis 5; +%hun& h%n*% 16=1; ku,%n# -%,i ;6 +%hun >Su-o*o -kk& 466<@ !en*e"% !en*e"%" " leukem leukemi% i% se(%uh se(%uh ini "elum "elum -ike+% -ike+%hui hui&& n%mun n%mun "%n*% "%n*%k k peneli+ peneli+i%n i%n *%n# *%n# -il%ku -il%kuk%n k%n un+uk meme%hk meme%hk%n %n m%s%l%h m%s%l%h ini' 7e"e,% 7e"e,%p% p%

peneli+ peneli+i%n i%n menun(uk menun(ukk%n k%n "%h/% "%h/%

leukem leukemi% i% le"ih le"ih se,in# se,in# men*e men*e,%n ,%n# # k%um k%um p,i% p,i% -i"%n-i"%n-in# in#k%n k%n k%um k%um /%ni+%& /%ni+%& -%n (u#% (u#% p%-% p%-% kelompok o,%n# kuli+ pu+ih -i"%n-in#k%n -en#%n o,%n# kuli+ hi+%m' N%mun s%mp%i s%%+ ini  "elum -ike+%hui men#%p% h%l +e,se"u+ -%p%+ +e,(%-i' !e,%n pe,%/%+ s%n#%+l%h pen+in# p%-% k%sus ini' !e,%n pe,%/%+ s%n#%+ "e,#un% un+uk  mem"e,ik%n %suh%n kepe,%/%+%n *%n# sesu%i -en#%n s+%n-%, kepe,%/%+%n -%n ko-e e+ik  -%l%m men%n#%ni p%sien -en#%n -i%#nos% leukemi% sesu%i -en#%n ilmu *%n# +el%h -ipel%(%,i' 12 R&m&'an R&m&'an Ma'ala Ma'ala 7%#%im%n% %suh%n kepe,%/%+%n p%-% klien -en#%n leukemi% 1 T&*&an &*&an Un+uk men#e+%hui %suh%n kepe,%/%+%n *%n# +ep%+ p%-% klien -en#%n leukemi%

 "e,-%s%,k%n p%+o3isiolo#i +e,(%-in*% leukemi%'

;

BAB II TINJAUAN TEORITIS 21 D#+,n, D#+,n,', ', Juml%h sel -%,%h pu+ihBleukosi+ no,m%l p%-% +u"uh ki+% "ekis%, %n+%,% :;66  11'666BL

>Cui& 4611@' Menu,u+ Meshe, p%-% +%hun >4611@& (uml%h leukosi+ *%n# +e,-%p%+ -i -%l%m +u"uh -e/%s% no,m%l "e,%-% p%-% ,en+%n# 5666  11'666BL' Juml%h leukosi+ "e,2%,i%si sesu%i umu, >7loom G F%/e++& 4664@' Leukemi% me,up%k%n su%+u pen*%ki+ *%n# -i+%n-%i -en#%n p,oli3e,%si -ini *%n# "e,le"ih%n -%,i sel -%,%h pu+ih' Leuk Leukem emi% i% (u#% (u#% "is% "is% -i-e -i-e3i 3ini nisi sik% k%n n se"% se"%#% #%ii ke#% ke#%n% n%s% s%n n hem% hem%+o +olo lo#i #iss %ki" %ki"%+ %+ p,os p,oses es neop neopl% l%s+ s+ik ik *%n# *%n# -ise -ise,+ ,+%i %i #%n# #%n##u #u%n %n -i3e -i3e,e ,ens nsi% i%si si p%-% p%-% "e," "e,"%# %#%i %i +in# +in#k% k%+% +%n n si in-u in-uk  k  hem%+opoie+i hem%+opoie+ik k >H%n-%*%ni >H%n-%*%ni G H%,i"o/o& H%,i"o/o& 4668@' Menu,u+ Menu,u+ )on# on# -kk p%-% +%hun >466<@& leukem leukemi% i% %-%l%h %-%l%h sekelo sekelompo mpok k pen*%k pen*%ki+ i+ #%n%s #%n%s p%-% p%-% sumsum sumsum +ul%n# +ul%n# "el%k% "el%k%n# n# -%n sis+em sis+em lim3%+ik *%n# -i+%n-%i -en#%n p,oli3e,%si +%np% "%+%s sel -%,%h pu+ih *%n# %"no,m%l -%n im%+u, >Don% G )on#& 466<@' Kesimp Kesimpul% ul%n n *%n# *%n# -%p%+ -%p%+ -i%m"i -i%m"ill %-%l%h %-%l%h "%h/% "%h/% leukem leukemi% i% me,up% me,up%k%n k%n su%+u su%+u pen*% pen*%ki+ ki+ -im%n% p,o-uksi sel -%,%h pu+ih s%n#%+ "e,le"ih%n mele"ihi (uml%h leukosi+ no,m%l -i -%l%m +u"uh *%n# "e,si3%+ %"no,m%l -%n im%+u,' Sel=sel ini men#h%m"%+ semu% sel l%in -i sumsum +ul%n# +ul%n# un+uk un+uk "e,kem "e,kem"%n "%n# # se%,% se%,% no,m%l no,m%l&& sehin# sehin##% #% me,ek% me,ek% +e,+im" +e,+im"un un -i sumsum sumsum +ul%n# +ul%n#'' K%,en% h%l +e,se"u+& leukemi% -ise"u+ su%+u #%n##u%n %kumul%+i3 sek%li#us #%n##u%n klon%l' Akhi,n*% sel=sel leukemik men#%m"il %lih sumsum +ul%n# -%n ini men*e"%"k%n k%-%, sel=sel nonleukemik -i -%l%m -%,%h menu,un' A-%pun kl%si3ik%si leukemi% -%p%+ -i(el%sk%n se"%#%i  "e,iku+$ A L# L#&$ &$#m #m,a ,a A$& $&!!

Leukem Leukemi% i% %ku+ %ku+ me,up% me,up%k%n k%n p,oli3 p,oli3e,%s e,%sii sel leukos leukosi+ i+ *%n# *%n# %"no,m %"no,m%l& %l& #%n%s& #%n%s& se,in# se,in# -ise,+%i "en+uk leukosi+ *%n# l%in -%,ip%-% no,m%l& (uml%hn*% "e,le"ih%n& se,+% -%p%+ men*e"%"k%n %nemi%& +,om"osi+openi%& -%n -i%khi,i -en#%n kem%+i%n >H%n-%*%ni G H%,i"o/o& 4668@' Menu,u+ Me3+% G Ho33",%n- p%-% +%hun >4668@& leukemi% %ku+ %-%l%h su%+u #%n##u%n m%li#n% -im%n% sel "l%s+ hemopoe+ik +e,-%p%+ se"%n*%k se"%n*%k le"ih -%,i 46 -%,i -%,i sel sums sumsum um +ul% +ul%n# n#'' Sel Sel p,im p,imi+i i+i33 "i%s "i%s%n* %n*%% (u#% (u#% "e,% "e,%ku kumu mul% l%si si -%l%m -%l%m -%,% -%,%h& h& men#in3il+,%si men#in3il+,%si (%,in#%n l%in& -%n men*e"%"k%n men*e"%"k%n #%#%l sumsum +ul%n#' +ul%n#' Leukemi% Leukemi% %ku+ menu,u+ kl%si3ik%si FA7 >F,enh=Ame,i%n=7,i+ish@ -%p%+ -ikl%si3ik%sik%n men(%-i -u%& *%i+u$

1. L#&$#m,a M,#l-.la'!,$ A$&!/ Acute  Acute Myeloid Myeloid Leukemia ( LMA LMA /AML) 5

Leuk Leukem emi% i% mielo mielo"l "l%s+ %s+ik ik %ku+ %ku+ %-%l% %-%l%h h su%+ su%+u u pen* pen*%k %ki+ i+ *%n# *%n# -i+% -i+%nn-%i %i -en# -en#%n %n +,%ns3o,m%si neopl%s+ik -%n #%n##u%n -i3e,ensi%si sel=sel p,o#eni+o, -%,i se,i m*eloi>Su-o*o -kk& 466<@' Leukemi% mielo"l%s+ik %ku+ >LMA@ me,up%k%n leukemi% *%n# men#en%i sel s+em hem%+o hem%+opoe poe+ik +ik *%n# *%n# kel%k kel%k "e,-i3 "e,-i3e,en e,ensi%s si%sii ke semu% semu% sel mieloi mieloi-' -' LMA me,up%k% me,up%k%n n leukemi% nonlim3osi+ik *%n# p%lin# se,in# +e,(%-i' Menu,u+ kl%si3ik%si FA7 >F,enh=Ame,i%n=7,i+ish@ LMA -i"%#i men(%-i en%m  (enis& *%i+u$ M1 $ Leukemi% mielo"l%s+ik +%np% pem%+%n#%n M4 $ Leukemi% mielo"l%s+ik -en#%n "e,"%#%i -e,%(%+ pem%+%n#%n M $ Leukemi% p,omielosi+ik hipe,#,%nul%, M: $ Leukemi% mielomonosi+ik M; $ Leukemi% mono"l%s+ik M5 $ E,i+,oleukemi% >H%n-%*%ni G H%,i"o/o& 4668@' 2 L#&$# L#&$#m,a m,a L,m+ L,m+-.l -.la'! a'!,$ ,$ A$&!/ A$&!/ Acute  Acute Lymphoblastic Lymphoblastic Leukemia Leukemia ( LLA LLA /ALL) LLA %-%l%h ke#%n%s%n klon%l -%,i sel=sel p,eku,so, lim3oi-' Le"ih -%,i 86

k%sus& sel=sel #%n%s "e,%s%l -%,i lim3osi+ 7& -%n sis%n*% me,up%k%n leukemi% sel T' Leukem Leukemi% i% ini me,up% me,up%k%n k%n "en+uk "en+uk leukem leukemi% i% *%n# *%n# p%lin# p%lin# "%n*%k "%n*%k p%-% p%-% %n%k=% %n%k=%n%k n%k'' )%l%up %l%upun un -emiki -emiki%n& %n& 46 -%,i -%,i k%sus k%sus LLA %-%l%h %-%l%h -e/%s% -e/%s% >Su-o* >Su-o*o o -kk& -kk& 466<@' 466<@' Kl%si3ik%si LLA %-%l%h se"%#%i "e,iku+$ %' Se%,% mo,3olo# mo,3olo#is& is& menu,u+ menu,u+ FA7 FA7 >F,enh& >F,enh& 7,i+ish& 7,i+ish& %n- Ame,i% Ame,i%n@ n@ LLA -i"%#i -i"%#i men(%-i +i#% (enis& *%i+u$ i' L1 $ LLA -en# -en#%n %n sel sel lim3o lim3o"l "l%s+ %s+ kei keil=k l=kei eil& l& neukl neukleo eoli li *%n# *%n# +i-% +i-%k k (el%s& (el%s& ii' ii'

-%n me,up%k%n 8: -%,i LLA& "i%s%n*% -i+emuk%n p%-% %n%k=%n%k L4 $ sel le"i le"ih h "es%, "es%,&& in+i in+i i,e#u i,e#ule le,& ,& k,om k,om%+ %+in in "e,# "e,#um ump% p%l& l& nukl nukleo eoli li (el%s (el%s&& -%n si+opl si+opl%sm %sm%% %#%k %#%k "%n*%k& "%n*%k& me,up% me,up%k%n k%n 1: -%,i -%,i LLA& LLA& "i%s%n* "i%s%n*%%

iii' iii'

+e,(%-i p%-% o,%n# -e/%s% L $ +ipe +ipe ini ini memili memiliki ki si+o si+opl pl%sm %sm%% "%so3 "%so3il il -en# -en#%n %n "%n* "%n*%k %k 2%ku 2%kuol ol%& %& -%n -%n

h%n*% me,up%k%n 1 -%,i LLA'  "' Se%,% imuno3eno+ipe LLA -%p%+ -i"%#i men(%-i emp%+ #olon#%n "es%, "es %, *%i+u se"%#%i "e,iku+$ i' Common ALL& ALL & 3,ekuensi ,el%+i3 p%-% %n%k=%n%k 95 -%n -e/%s% ;1' ii'  Null ALL& ALL& 3,ekuensi ,el%+i3 p%-% %n%k=%n%k 14 -%n -e/%s% 8' iii' T-ALL& T-ALL& 3,ekuensi ,el%+i3 p%-% %n%k=%n%k 14 -%n -e/%s% 16' i2'  B-ALL&  B-ALL& 3,ek 3,ekue uens nsii ,el% ,el%+i +i33 p%-% p%-% %n%k %n%k=% =%n% n%k k 1 -%n -%n -e/% -e/%s% s% 4 >H%n-%*%ni G H%,i"o/o& 4668@ De3enisi su"+ipe imunolo#i ini "e,-%s%,k%n %+%s %-% %+%u +i-%kn*% "e,"%#%i %n+i#en  pe,muk%%n sel' Su"+ipe imunolo#i *%n# *%n# p%lin# se,in# -i+emuk%n %-%l%h common ALL.  Null cell ALL "e,%s%l ALL "e,%s%l -%,i sel s el *%n# s%n#%+ p,imi+i3 -%n le"ih "%n*%k p%-% -e/%s%'  B-

9

 ALL me,up% me,up%k%n k%n pen*%ki pen*%ki++ *%n# *%n# s%n#%+ s%n#%+ (%,%n#& (%,%n#& -en#%n -en#%n mo,3ol mo,3olo#i o#i L *%n# *%n# se,in# se,in#  "e,pe,il%ku se"%#%i lim3om% %#,esi3 >Su-o*o -kk& 466<@' 466<@'

B L# L#&$ &$#m #m,a ,a K"K"-n, n,$ $

Leukemi% k,onik memiliki sel -%,%h *%n# %"no,m%l m%sih -%p%+ "e,3un#si& -%n o,%n# -en#%n leukemi% (enis ini mun#kin +i-%k menun(ukk%n #e(%l%' !e,l%h%n=l%h%n& leukemi% k,onik mem"u,uk -%n mul%i menun(ukk%n #e(%l% ke+ik% sel leukemi% "e,+%m"%h "%n*%k  -%n p,o-uksi sel no,m%l no,m%l "e,ku,%n#' "e,ku,%n#' !%-% s+%-ium s+%-ium -ini leukemi% k,onik& sel leukemi% leukemi% -%p%+ "e,3un#si h%mpi, sepe,+i sel no,m%l' 1 L#&$# L#&$#m,a m,a M#l M#l-, -, K"K"-n,$ n,$ (LMK) (LMK) Leukemi% m*eloi- k,onik me,up%k%n leukemi% *%n# pe,+%m% -i+emuk%n se,+%

-ike+%h -ike+%hui ui p%+o#e p%+o#enesi nesisn* sn*%' %' !%-% !%-% +%hun +%hun 1<56 1<56 No/ell No/ell -%n Hun#e, Hun#e,3o, 3o,- menemu menemuk%n k%n kel%in%n k,omosom *%n# sel%lu s%m% p%-% p%sien LMK& *%i+u 44 %+%u hil%n#n*% se"%# se"%#i%n i%n len# len#%n %n p%n(% p%n(%n# n# -%,i -%,i k,om k,omos osom om 44& 44& *%n# *%n# s%%+ s%%+ ini ini ki+% ki+% ken% ken%ll se"%# se"%#%i %i k,omosom !hil%-elphi% >!h@' Sel%n(u+n*% -i +%hun 1<9 Ro/le menemuk%n "%h/% k,omosom !h +e,"en+uk %ki"%+ %-%n*% +,%nslok%si ,esip,ok%l %n+%,% len#%n p%n(%n# k,omosom < -%n 44' Den#%n kem%(u%n -i "i-%n# "iolo#i molekul%,& p%-% +%hun 1<86 -ike+%h -ike+%hui ui "%h/% "%h/% p%-% p%-% k,omos k,omosom om 44 *%n# *%n# men#%l men#%l%mi %mi pemenpemen-ek% ek%n n +%-i& +%-i& +e,n* +e,n*%+% %+% -i-%p%+k%n %-%n*% #%"un#%n %n+%,% #en *%n# %-% -i len#%n p%n(%n# k,omosom < *%kni A7L > Abelson@  Abelson@ -en#%n #en 7CR > Break > Break Cluster Region@ Region@ *%n# +e,le+%k -i len#%n  p%n(%n# k,omosom 44' ?%"un#%n ke-u% #en ini se,in# -i+ulis se"%#%i 7CR=A7L -i-u -i-u#% #% ku%+ ku%+ se"%# se"%#%i %i pen* pen*e" e"%" %" u+%m u+%m%% +e,(%+e,(%-in* in*%% kel%i kel%in% n%n n p,ol p,oli3 i3e,% e,%si si -%,i -%,i se,i se,i #,%nulosi+ +%np% #%n##u%n -i3e,ensi%si sehin##% p%-% %pus%n -%,%h +epi ki+% -%p%+ -en#%n -en#%n mu-%h mu-%h melih% melih%++ +in#k% +in#k%+%n +%n -i3e,e -i3e,ensi% nsi%si si se,i #,%nul #,%nulosi osi++ p%-% p%-% p%sien p%sien LMK  >Su-o*o -kk& 466<@'

2 L#&$# L#&$#m,a m,a L,m+ L,m+-', -',!,$ !,$ K"K"-n,$ n,$ (LLK (LLK)) Leukemi% lim3osi+ik k,onik %-%l%h su%+u ke#%n%s%n hem%+olo#ik *%n# -i+%n-%i

oleh p,oli3e,%si klon%l -%n penumpuk%n penumpuk%n lim3osi+ lim3osi+ 7 neopl%s+ik neopl%s+ik -%l%m -%,%h& sumsum +ul%n# +ul%n#&& lim3on lim3ono-i o-i&& limp%& limp%& h%+i& h%+i& -%n o,#%n= o,#%n=o,# o,#%n %n l%inn* l%inn*%' %' LLK ini m%suk m%suk -%l%m -%l%m kel%in%n kel%in%n lim3op,oli3e, lim3op,oli3e,%+i3' %+i3' T%n-%=+%n-% %n-%=+%n-%n*% n*% melipu+i melipu+i lim3osi+osis lim3osi+osis&& lim3%-enop%+ lim3%-enop%+i& i& -%n splenome#%li' Ke"%n*%k%n LLK ><;@ %-%l%h neopl%sm% sel 7& sis%n*% neopl%sm% sel T >Su-o*o -kk& 466<@' Menu,u+ RAI& LLK +e,"%#i men(%-i ; s+%-ium *%i+u$ O >Lim3osi+osis -%,%h +epi -%n sumsum +ul%n#@& I >Lim3osi+osis  pem"es%,%n lim3ono-i@& II >Lim3osi+osis  8

splenome#%liBhep%+ome#%li@& III >Lim3osi+osis  %nemi%& H" ku,%n# -%,i 11 #,%mB-L@& I >Lim3osi+osis  +,om"osi+openi%& +,om"osi+ ku,%n# -%,i 166'666BuL@' Se-%n#k%n menu,u+ 7ine+& LLK +e,"%#i men(%-i  s+%-ium *%i+u$ A >Lim3osi+osis -%,%h +epi -%n sumsum +ul%n# @& 7 >ku,%n# -%,i  -%e,%h lim3oi- *%n# mem"es%,& Lim3osi+osis -%,%h +epi& -%n sumsum +ul%n# @& C > -%e,%h lim3oi- *%n# mem"es%,& s+%-ium 7  %nemi%& H" ku,%n# -%,i 11 #B-L p%-% p,i% -%n ku,%n# -%,i 16 #,B-L p%-% pe,empu%n %+%u +,om"osi+openi% >ku,%n# -%,i 166'666BL@' !%sien -en#%n LLK -%p%+ menun(ukk%n "e,"%#%i komplik%si %ki"%+ p,o#,esi2i+%s  pen*%ki+n*%' a In+#$', In3eksi me,up%k%n komplik%si -%n pen*e"%" u+%m% kem%+i%n' S. pneumoniae& pneumoniae & S. aureus aureus&& -% - %n  . influen!a me,up%k%n me,up%k%n o,#%nism *%n# se,in# -i(ump%i p%-%  p%sien LLK *%n# +i-%k -i"e,ik%n +e,%pi imunosup,esi' imunosup,esi' . H,H,-%a %ama% ma%ll-.& .&l,n l,n#m #m,a ,a H%l ini -i(ump%i -i(ump%i le"ih le"ih -%,i -%,i 55 p%sien %khi, pen*%k pen*%ki+ i+ ini' ini' Semu% Semu% kel%s kel%s immuno#lo"ulin >I#?& I#A& -%n I#M@ "i%s%n*% menu,un& meskipun (u#% -i(ump%i h%n*% s%+u %+%u -u% immuno#lo"ulin s%(% *%n# +u,un' 3 T" T"an'+ an'+-"ma -"ma', ', M#n*a, M#n*a, K#%ana'a K#%ana'an n L,m+-, L,m+-, an% A%"# A%"#',+  ',+  T,%ns3o,m%si ini +e,(%-i seki+%, 16  1;' Y%n# Y%n# p%lin# se,in# %-%l%h sin-,om% s in-,om% Ri+he Ri+he,, >;@ >;@ -%n leukem leukemi% i% p,olim p,olim3os 3osi+ik i+ik'' !%sien !%sien -en#%n -en#%n sin-,o sin-,om% m% Ri+he Ri+he,  ,  >lim3om% >lim3om% sel "es%,@ se,in# -i-%p%+k%n -i-%p%+k%n lim3%-enop%+i lim3%-enop%+i -%n hep%+osplen hep%+osplenome#%l ome#%lii *%n# p,o#,esi3& -em%m& n*e,i %"-omen& penu,un%n "e,%+ "%-%n& %nemi%& -%n +,om"osi+openi% p,o#,esi3'

 K-ml,$a' K-ml,$a',, A$,.a! A$,.a! P#na$,! P#na$,! A&!-,m& A&!-,m&n n   *%n# posi+i3 >Coom"s Komplik%si +e,(%-i (ik% +e,-%p%+ +es %n+i #lo"ulin "irect  *%n# Test @& @& %nemi% hemoli+ik& +,om"osi+openi%& neu+,openi%& -%n %pl%si% sel -%,%h me,%h mu,ni >Su-o*o -kk& 466<@'

22 E!,-lE!,-l-%, %,

Se"%#i%n Se"%#i%n "es%, pen-e,i+% leukemi% memiliki memiliki 3%k+o,=3%k+o 3%k+o,=3%k+o,, pen*e"%" pen*e"%" *%n# +i-%k -%p%+ -ii-en+i3ik%si -ii-en+i3ik%si&& +e+%pi %-% "e"e,%p% "e"e,%p% 3%k+o, *%n# +e,"uk+i +e,"uk+i -%p%+ men*e"%"k%n men*e"%"k%n leukemi% sesu%i -en#%n kl%si3ik%sin*%' A L#&$#m,a L#&$#m,a M,#l-.la'! M,#l-.la'!,$ ,$ A$&!/ A$&!/ Acute  Acute Myeloid Leukemia Leukemia ( LMA LMA /AML) E+iolo#i -%,i LMA se"%#i%n "es%, +i-%k -ike+%hui' Meskipun -emiki%n %-% "e"e,%p%

3%k+o, *%n# -ike+%hui -ike+%hui -%p%+ men*e"%"k%n men*e"%"k%n %+%u se+i-%kn*% se+i-%kn*% men(%-i 3%k+o, p,e-isposisi p,e-isposisi LMA p%-% popul%si +e,+en+u' 7enene su%+u sen*%/% kimi% *%n# "%n*%k -i#un%k%n p%-%

<

in-us+,i in-us+,i pen*%m%k%n pen*%m%k%n kuli+ -i ne#%,% *%n# se-%n# "e,kem"%n#& "e,kem"%n#& -ike+%hui me,up%k%n me,up%k%n %+ leukomo#en leukomo#enik ik un+uk un+uk LMA' Sel%in i+u ,%-i%si ionik (u#% -ike+%hui -%p%+ men*e"%"k% men*e"%"k%n n LMA' Ini -ike+%hui -%,i peneli+i%n +in##in*% insi-iensi k%sus leukemi%& +e,m%suk LMA&  p%-% o,%n# o,%n# *%n# sel%m%+ -%,i se,%n#%n "om %+om -i Hi,oshim% -%n N%#%s%ki p%-% +%hun 1<:;' E3ek -%,i leukomo#enik -%,i p%p%,%n ion ,%-i%si +e,se"u+ mul%i +%mp%k se(%k  1&; +%hun sesu-%h pen#e"om%n -%n men%p%i pun%kn*% 5 s %mp%i 9 +%hun' B L#& L#&$# $#m,a m,a L,m+-. L,m+-.la' la'!,$ !,$ A$&! A$&!// Acute  Acute Lymphoblastic Lymphoblastic Leukemia Leukemia ( LLA LLA /ALL)

!en*e"%" LLA p%-% -e/%s% se"%#i%n "es%, +i-%k -ike+%hui' F%k+o, ke+u,un%n -%n sin-,om% p,e-isposisi #ene+ik le"ih "e,hu"un#%n -en#%n LLA *%n# +e,(%-i p%-% %n%k= %n%k' 7e"e,%p% 3%k+o, lin#kun#%n -%n kon-isi klinis *%n# "e,hu"un#%n -en#%n LLA& *%i+u$ 1' R%-i%si R%-i%si ionik' ionik' O,%n#=o,%n# O,%n#=o,%n# *%n# *%n# sel%m%+ sel%m%+ -%,i le-%k%n le-%k%n "om "om %+om -i Hi,oshi Hi,oshim% m% -%n  N%#%s%ki mempun*%i ,isiko ,el%+i3 keselu,uh%n un+uk "e,kem"%n# men(%-i men(%-i LLA 4' !%p% !%p%,%n ,%n -en# -en#%n %n "en "enen enee k%-% k%-%,, +in# +in##i #i -%p% -%p%++ men* men*e" e"%" %"k% k%n n ke,u ke,us%k s%k%n %n sums sumsum um +ul%n#& ke,us%k%n k,omosom ' Me,okok Me,okok se-iki+ se-iki+ menin#k% menin#k%+k%n +k%n ,isiko ,isiko LLA LLA p%-% p%-% usi% -i%+%s -i%+%s 56 +%hun' +%hun'

4 L#&$#m,a L#&$#m,a M#l-, M#l-, K"-n K"-n,$ ,$ (LMK) (LMK) !en*e"%" p%s+i LMK "elum -ike+%hui se%,% p%s+i' Te+%pi LMK menin#k%+ se+el%h

 pe,is+i/% "om %+om -i N%#%s%ki N% #%s%ki -%n Hi,oshim%& -%n (u#% -i Rusi% se+el%h ,e%k+o, %+om Che,no"il mele-%k' Den#%n k%+% l%in& ,%-i%si ionik men*e"%"k%n +e,(%-in*% LMK' D L#&$#m,a L#&$#m,a L,m+-',!,$ L,m+-',!,$ K"-n,$ K"-n,$ (LLK) (LLK) !en* !en*e" e"%" %" LLK LLK m%sih m%sih "elum "elum -ike -ike+% +%hu hui' i' Kemun Kemun#k #kin in%n %n *%n# *%n# "e,p "e,pe, e,%n %n %-%l% %-%l%h h

%"no,m%li+%s k,omosom& onko#en& -%n ,e+,o2i,us >RNA > RNA +umou, +umou, 2i,us@' 2 Man,+#'! Man,+#'!a', a', Kl,n,$  Kl,n,$   A. L#&$#m,a M,#l-.la'!,$ A$&!/ Acute  Acute Myeloid Myeloid Leukemia ( LMA LMA /AML)

LMA "e,"e-% "e,"e-% -en#%n -en#%n %n##%p %n##%p%n %n umum umum sel%m% sel%m% ini -im%n% -im%n% p%-% p%-% p%sien p%sien LMA +i-%k  sel%lu -i(ump%i leukosi+osis' Leukosi+osis +e,(%-i p%-% seki+%, ;6 k%sus LMA& se-%n# 1; p%sien mempun*%i %n#k% leukosi+ *%n# no,m%l& -%n seki+%, ; p%sien men#%l%mi ne+,openi%' T%n-% -%n #e(%l% u+%m% LMA %-%l%h %-%n*% ,%s% lel%h& pe,-%,%h%n& -%n in3eksi *%n# -ise"%"k%n -ise"%"k%n oleh sin-,om sin-,om ke#%#%l%n ke#%#%l%n sumsum +ul%n# se"%#%im%n% se"%#%im%n% -ise"u+k%n -ise"u+k%n -i %+%s' !e,-%,%h%n "i%s%n*% +e,(%-i -%l%m "en+uk pu,pu,% %+%u pe+eki% *%n# se,in# -i (ump%i 16

 p%-% eks+,emi+%s "%/%h %+%u %+% u "e,up% epis+%ksis& pe,-%,%h%n #usi& -%n ,e+in%' In3eksi se,in# +e,(%-i -i +en##o,ok% +en##o,ok%n& n& p%,u=p%,u& p%,u=p%,u& kuli+& -%n -%e,%h pe,i ,ek+%& sehin##% sehin##% o,#%n=o,# o,#%n=o,#%n %n +e,se"u+ +e,se"u+ h%,us -ipe,iks% -ipe,iks% se%,% +eli+i p%-% p%sien p%sien LMA -en#%n -en#%n -em%m -em%m >Su-o*o -kk& -kk& 466<@' H%l ini -%p%+ -ise"%"k%n -i3e,ensi%si sel ke "%#i%n m*eloi- khususn*% monosi+' Monosi+ "e,pe,%n -%l%m sis+em ,e+ikuloen-o+eli%l >RES@ *%n# melipu+i m%k,o3%# %l2eol%,  -%l%m p%,u& kuli+& -%n m%k,o3%# p%-% usus >Meh+% G Ho33",%n-& 4668@' !%sien -en#%n %n#k% leukosi+ *%n# sen#%+ +in##i >le"ih -%,i 166 ,i"uBmm @& se,in# +e,(%-i leukos+%sis& *%i+u +e,(%-in*% #ump%l%n leukosi+ *%n# men*um"%+ %li,%n pem"uluh -%,%h -%,%h 2en% 2en% m%upun m%upun %,+e,i' %,+e,i' ?e(%l% ?e(%l% leukos leukos+%si +%siss s%n#%+ s%n#%+ "e,2%, "e,2%,i%si i%si&& +e,#%n +e,#%n+un +un# # lok%si lok%si sum"%+%nn*%' ?e(%l% *%n# se,in# -i(ump%i %-%l%h #%n##u%n kes%-%,%n& ses%k n%3%s& n*e,i -%-%& -%-%& -%n p,i%pi p,i%pismu smus' s' An#k% An#k% leukos leukosi+ i+ *%n# *%n# s%n#%+ s%n#%+ +in##i +in##i (u#% (u#% se,in# se,in# menim" menim"ulk ulk%n %n #%n##u%n me+%"olisme "e,up% hipe,u,isemi%' Hipe,u,isemi% +e,(%-i %ki"%+ sel=sel leukosi+ *%n# "e,p,oli3e,%si "e,p,oli3e,%si se%,% ep%+ -%l%m (uml%h *%n# "es%,' In3il+,%si In3il+,%si sel=sel "l%s+ %k%n men*e"%"k%n men*e"%"k%n +%n-%B#e(%l% +%n-%B#e(%l% *%n# "e,2%,i%si "e,2%,i%si +e,#%n+un# +e,#%n+un# o,#%n o,#%n *%n# -i in3il+,%si' In3il+,%si sel=sel "l%s+ -i kuli+ %k%n men*e"%"k%n men*e"%"k%n leukemi% ku+is *%i+u "e,up% "en(ol%n *%n# +i-%k "e,pi#men -%n +%np% ,%s% s%ki+& se-%n# in3il+,%si -i sel= sel "l%s+ -i (%,in#%n lun%k %k%n men*e"%"k%n men*e"%"k%n no-ul no-ul -i "%/%h kuli+ >klo,om%@' >klo,om%@' In3il+,%si In3il+,%si sel=sel "l%s+ -i -%l%m +ul%n# %k%n men*e"%"k%n n*e,i +ul%n# *%n# spon+%n %+%u -en#%n s+imul%si ,in#%n' !em"en#k%k%n #usi se,in# -i(ump%i se"%#%i m%ni3es+%si in3il+,%si sel=sel  "l%s+ ke -%l%m #usi' B L#& L#&$# $#m,a m,a L,m+-.l L,m+-.la'! a'!,$ ,$ A$&! A$&!// Acute  Acute Lymphoblastic Lymphoblastic Leukemia Leukemia ( LLA LLA /ALL)

!,esen+%si klinis LLA s%n#%+ "e,2%,i%si' !%-% umumn*% #e(%l% klinis men##%m"%,k%n ke#%#%l%n sumsum +ul%n# %+%u ke+e,li"%+%n eks+,%me-ul%, oleh sel leukemi%' Akumul%si sel=sel lim3o"l%s #%n%s -i sumsum +ul%n# men*e"%"k%n ku,%n#n*% sel=sel no,m%l -i -%,%h pe,i3e, -%n #e(%l% klinis -%p%+ "e,hu"un#%n -en#%n %nemi%& in3eksi& -%n pe,-%,%h%n >Su-o* >Su-o*o o -kk& -kk& 466<@' 466<@' Anemi Anemi%% p%-% p%-% p%sien p%sien LLA men*e"%" men*e"%"k%n k%n kelem% kelem%h%n h%n&& -*spne -*spne%& %&  "%hk%n #%#%l (%n+un# kon#es+i3' Se-%n#k%n pe,-%,%h%n *%n# +e,(%-i me,up%k%n %ki"%+ -%,i +,om"osi+openi% >7u,ke& 4614@' Dem%m %+%u in3eksi *%n# (el%s -%p%+ -i+emuk%n p%-% sep%,uh sep%,uh p%sien p%sien LLA& LLA& se-%n#k se-%n#k%n %n #e(%l% #e(%l% pe,-%, pe,-%,%h%n %h%n p%-% p%-% sepe,+ sepe,+i#% i#% p%sien p%sien *%n# *%n# "%,u "%,u -i-i%#nosis LLA' !e,-%,%h%n *%n# "e,%+ (%,%n# +e,(%-i'

4 L#&$ L#&$#m,a #m,a M#l-, M#l-, K"-n,$ K"-n,$ (LMK) (LMK)

11

LMK -i"%#i men(%-i  3%se "e,-%s%,k%n pe,(%l%n%n pen*%ki+n*%& *%kni 3%se k,onik& 3%se %ksele,%si& -%n 3%se k,isis "l%s+' !%-% umumn*% umumn*% s%%+ pe,+%m% pe,+%m% -i%#nosis -i%#nosis -i+e#%kk%n& -i+e#%kk%n&  p%sien m%sih -%l%m 3%se k,onis& "%hk%n se,in# k%li -i%#nosis LMK -i+emuk%n se%,% ke"e+ul%n& mis%ln*% p%-% pe,si%p%n p,% ope,%si& -im%n% -i+emuk%n leukosi+osis he"%+ +%np% +%np% #e(%l% #e(%l% #e(%l% #e(%l% in3eks in3eksi' i' !%-% !%-% 3%se 3%se k,onis k,onis&& p%sien p%sien se,in# se,in# men#el men#eluh uh me,%s% me,%s% ep%+ ep%+ ken*%n#' H%l ini -ise"%"k%n k%,en% pem"es%,%n limp% -im%n% limp% men-es%k l%m"un#' Keluh%n l%in se,in# +i-%k spesi3ik& mis%ln*%$ ,%s% ep%+ lel%h& lem%h& -em%m *%n# +i-%k  +e,l%lu +in##i& ke,in#%+ m%l%m' !enu,un%n "e,%+ "%-%n +e,(%-i se+el%h pen*%ki+ "e,l%n#sun# l%m%' Semu% keluh%n +e,se" +e,se"u+ u+ me,up% me,up%k%n k%n #%m"%, #%m"%,%n %n hipe,m hipe,me+%" e+%"oli olisme sme %ki"%+ %ki"%+ p,oli3 p,oli3e,%s e,%sii sel=sel sel=sel leukem leukemi%' i%' Se+el%h 4= +%hun& "e"e,%p% p%sien pen*%ki+n*% men(%-i le"ih p,o#,esi3 %+%u men#%l%mi %ksel %ksele,% e,%si si'' 7il% 7il% s%%+ s%%+ -i%# -i%#no nos% s% -i+e -i+e#% #%kk kk%n %n&& p%sie p%sien n "e,% "e,%-% -% p%-% p%-% 3%se 3%se k,on k,onis& is& m%k% m%k% kel%n#sun# kel%n#sun#%n %n hi-up "e,kis%, %n+%,% 1 s%mp%i 1&; +%hun' Ci,i kh%s 3%se %ksele,%si %ksele,%si %-%l%h leukos leukosi+o i+osis sis *%n# *%n# suli+ suli+ -ikon -ikon+,ol +,ol oleh oleh o"%+=o o"%+=o"%+ "%+ mielos mielosup, up,esi3 esi3&& mielo" mielo"l%s l%s -i pe,i3e,  pe,i3e,  men%p%i 1;=6& p,omielosi+ le"ih -%,i 6& -%n +,om"osi+ ku,%n# -%,i 166'666Bmm ' Se%,% klinis& 3%se ini -%p%+ -i-u#% "il% limp% *%n# +%-in*% su-%h men#eil -en#%n +e,%pi& kem"%l kem"%lii mem"es% mem"es%,& ,& keluh keluh%n %n %nemi% %nemi% "e,+%m "e,+%m"%h "%h "e,%+& "e,%+& +im"ul +im"ul pe+eki pe+ekie& e& ekimosi ekimosis' s' 7il% 7il% -ise,+%i -ise,+%i -em%m& "i%s%n*% "i%s%n*% +e,-%p%+ +e,-%p%+ in3eksi' in3eksi' !%-% seki+%, 1B pen-e,i+%& pen-e,i+%& pe,u"%h%n +e,(%-i se%,% men-%-%k +%np% -i-%hului m%s% p,o-,om%l& ke%-%%n ini -ise"u+ k,isis "l%s+' D L#&$ L#&$#m,a #m,a L,m+-, L,m+-, K"-n K"-n,$ ,$ (LLK) (LLK)

A/%l -i%#nosis& -i%#nosis& ke"%n*%k%n ke"%n*%k%n p%sien LLK +i-%k menun(ukk%n menun(ukk%n #e(%l% >%simp+om%+ik@' >%simp+om%+ik@' !%-% !%-% p%sien p%sien -en#%n -en#%n #e(%l%& #e(%l%& p%lin# p%lin# se,in# se,in# -i+emu -i+emuk%n k%n lim3%lim3%-eno enop%+i p%+i&& penu,u penu,un%n n%n "e,%+ "e,%+  "%-%n& -%n kelel%h%n' ?e(%l% l%in melipu+i hil%n#n*% n%3su m%k%n -%n penu,un%n kem%mpu%n l%+ih%nBol%h,%#%' Dem%m& ke,in#%+ m%l%m& -%n in3eksi (%,%n# +e,(%-i p%-% %/%ln*% %/%ln*%&& +e+%pi +e+%pi sem%ki sem%kin n men*o men*olok lok se(%l%n se(%l%n -en#%n -en#%n pe,(%l%n% pe,(%l%n%n n pen*%ki pen*%ki+n* +n*%' %'

Aki"%+ Aki"%+

 penumpuk%n sel 7 neopl%s+ik& p%sien *%n# %simp+om%+ik p%-% s%%+ -i%#nosis p%-% %khi,n*% men#%l%mi lim3%-enop%+i& splenome#%li& -%n hep%+ome#%li'

25 E6al&a', E6al&a', D,a%n-'! D,a%n-'!,$  ,$ 

!eme,iks%%n !eme,iks%%n -i%#nos+ik -i%#nos+ik *%n# -il%kuk%n -il%kuk%n p%-% klien -en#%n -en#%n leukemi% leukemi% %-%l%h se"%#%i  "e,iku+$

14

1' D%,%h len#k%p$ menun(ukk%n %-%n*% penu,un%n penu,un%n hemo#lo"in& hemo#lo"in& hem%+ok,i+& (uml%h sel -%,%h me,%h& -%n +,om"osi+' Juml%h sel -%,%h pu+ih menin#k%+ p%-% leukemi% k,onik& +e+%pi (u#% -%p%+ +u,un& no,m%l& %+%u +in##i p%-% leukemi% %ku+ 4' Aspi,%si sumsum +ul%n# -%n "iopsi mem"e,ik%n -%+% -i%#nos+ik -i%#nos+ik -e3ini+i3 ' As%m u,%+ se,um menin#k%+ k%,en% pelep%s%n oksipu,in se+el%h kelu%, m%sukn*% m%sukn*% sel= sel leukemi% ep%+ -%n pen##un%%%n pen##un%%%n o"%+ si+o+oksi+ :' Sin%,  -%-%$ -%-%$ un+uk un+uk men#e+%hui men#e+%hui lu%sn*% lu%sn*% pen*%ki+ pen*%ki+ ;' !,o3il kimi%& EK?& -%n kul+u, spesimen un+uk men*in#ki,k%n m%s%l%h %+%u pen*%ki+ l%in *%n# +im"ul'

1

27 Web Of Caution (WOC)

Kel%in%n k,omosom& ,%-i%si ionik& +e,p%(%n "%h%n="%h%n kimi%& pen##un%%n o"%+=o"%+ imunosup,esi3  !,oli3e,%si sel k%nke,  Sel k%nke, "e,s%in# -en#%n sel no,m%l un+uk men-%p%+k%n nu+,isi

In3il+,%si Sel no,m%l -i#%n+i -en#%n sel k%nke, 

In3il+,%si Eks+,%me-ul%, 

Akumul%si sel -%,%h  pu+ih -i sumsum +ul%n#

!em"es%,%n limp% >splenome#%li@ -%n  pem"es%,%n h%+i >hep%+ome#%li@

E,i+,osi+ menu,un

T,om"osi+ menu,un

Anemi%

T,om"osi+openi%&  p+ekie& epis+%ksis

Sel keku,%n#%n oksi#en -%n nu+,isi

77 menu,un

!e,-%,%h%n

Kelem%h%n

M$8 Gan%%&an "a'a naman n#",

Men-es%k l%m"un#

Ano,eksi%& mu%l& -%n mun+%h

M$8 A$!&al/R,',$A$!&al/R,',$!,n%%, #n&"&nan 6-l&m# 3a,"an

M$8 In!-l#"an', a$!,6,!a' M$8 Gan%%&an $#.&!&an n&!",', $&"an% a", $#.&!&an !&.&

1:

29 P#na!ala$'anaan P#na!ala$'anaan M#,' 7e,iku+ 7e,iku+ %-%l%h %-%l%h pen%+%l pen%+%l%ks %ks%n%% %n%%n n se%,% se%,% me-is me-is *%n# *%n# -%p%+ -%p%+ -i"e,ik -i"e,ik%n %n kep%-% kep%-% p%sien p%sien

leukemi% "e,-%s%,k%n kl%si3ik%si %+%u +ipe -%,i leukemi%' A L#&$ L#&$#m,a #m,a M,#l-.la'! M,#l-.la'!,$ ,$ A$&!/ A$&!/ Acute  Acute Myeloid Leukemia Leukemia (LMA/AML) (LMA/AML) Te,%pi Te,%pi *%n# -%p%+ -i"e,ik%n kep%-% p%sien LMA %-%l%h se"%#%i "e,iku+$ 1' Kemo Kemo+e +e,% ,%pi pi me,u me,up% p%k% k%n n "en+ "en+uk uk +e,%p +e,%pii u+%m u+%m%% -%n -%n p%-% p%-% "e"e "e"e,%p ,%p%% k%su k%suss -%p% -%p%++ men#h%silk%n pe,"%ik%n *%n# "e,l%n#sun# s%mp%i se+%hun %+%u le"ih' O"%+ *%n#  "i%s%n*% -i#un%k%n melipu+i mel ipu+i -%uno,u"iin& h*-,ohlo,i-e h *-,ohlo,i-e >e,u"i-ine@& >e, u"i-ine@& *+%,%"ine >C*+os%,=U@& -%n me,%p+opu,ine >pu,ine+hol@ 4' !em"e,i%n !em"e,i%n p,o-u p,o-uk k -%,%h -%,%h -%n pen%n#%n%n pen%n#%n%n in3eksi in3eksi -en#%n -en#%n se#e,% se#e,% ' T,%nsp T,%nspl%n l%n+%si +%si sumsum sumsum +ul%n# +ul%n#'' Se"%ikn*% p%sien -i,u(uk ke spesi%lis pen*%ki+ -%l%m >su" 7%#i%n Hem%+olo#i@ un+uk   pen%+%l%ks%n%%n le"ih l%n(u+ >Mu++%in -kk& 466<@'

B L#& L#&$# $#m,a m,a L,m+-. L,m+-.la' la'!,$ !,$ A$&! A$&!// Acute  Acute Lymphoblastic Lymphoblastic Leukemia Leukemia ( LLA LLA /ALL)

7en+uk +e,%pi u+%m% -%l%m pen%n#%n%n m%s%l%h LLA %-%l%h kemo+e,%pi' Kemo+e,%pi un+uk LLA *%n# p%lin# men-%s%, +e,-i,i %+%s p%n-u%n o"%+' I'

In-uksi ,emisi Tu(u%n -%,i +e,%pi in-uksi ,emisi %-%l%h men%p%i ,emisi kompli+ hem%+olo#ik  sehin##% hem%+opoiesis -%p%+ kem"%li no,m%l' %' O"%+ O"%+ *%n# *%n# -i#un% -i#un%k%n k%n +e,-i,i +e,-i,i %+%s$ %+%s$ 1@ in,i in,is+in s+inee >CR@ >CR@  1&; 1&; m#Bm m#Bm4Bmin##u se%,% I 4@ !,e!,e-ni niso son n >!,e >!,e-@ -@  5 m#B m#Bm m4Bh%,i se%,% o,%l @ L'Asp% L'Asp%,%# ,%#in% in%se se >L'%sp >L'%sp@@  16'66 16'666 6 UBm4 :@ D%uno, D%uno,u"i u"iin in >DNR@ >DNR@  4; m#Bm m#Bm 4Bmin##u=: min##u'  "' Re#imen *%n# -i#un%k%n un+uk un+uk LLA -en#%n ,isiko s+%n-%, +e,-i,i %+%s$ 1@ !,e!,e-ni niso son n  CR CR 4@ !,e-ni !,e-nison son  CR  L' L' Asp% Asp%,%# ,%#in% in%se' se' ' Re#imen Re#imen un+uk ALL -en#%n -en#%n ,isiko +in##i +in##i %+%u ALL p%-% o,%n# o,%n# -e/%s% -e/%s% %n+%,% l%in $ 1@ !,e-nison !,e-nison  CR  DNR DNR -en#%n -en#%n %+%u %+%u +%np% +%np% L'Asp%,%#in L'Asp%,%#in%se %se 4@ DNR DNR  CR  !,e!,e-ni niso son n  L'As L'Asp% p%,% ,%#i #in% n%se se -en# -en#%n %n %+%u %+%u +%np +%np%% siklo3os3%mi-'

I I'

Te,%pi po pos+=,emisi %' Te,%pi un+uk  sanctuar# p$ase >mem"%smi sel leukemi% *%n# "e,sem"un*i -%l%m SS! -%n +es+is@  "' Te,%pi Te,%pi in+ensi3ik%siBkonsoli-%si$ pem"e,i%n ,e#imen non-cro non-cross ss resistant  resistant  +e,h%-%p ,e#imen in-uksi ,emisi *%n# "e,+u(u%n un+uk mene#%h ,el%ps -%n  (u#% +im"uln*% sel *%n# ,esis+en o"%+

1;

' Te,%pi ,%pi pem pemel elih ih%, %,%% %%n n >maintenance% >maintenance%$$ umumn*% -i#un%k%n 5 me,%p+opu,ine >5 M!@ pe, o,%l& -i"e,ik%n sel%m% 4= +%hun -en#%n -iselin#i +e,%pi konsoli-%si' 4 L#&$#m,a L#&$#m,a M#l-, M#l-, K"-n K"-n,$ ,$ (LMK) (LMK) Me-ik%si %+%upun +e,%pi *%n# -%p%+ -i"e,ik%n kep%-% p%sien -en#%n LMA *%i+u$ %' 7usulph%n 7usulph%n >m*le,% >m*le,%n@$ n@$ -osis -osis 6&1=6&4 6&1=6&4 m#Bk# m#Bk# 77Bh%,i& 77Bh%,i& +e,%pi +e,%pi -imul%i -imul%i (ik% leukosi leukosi++

n%ik n%ik men(%men(%-ii ;6'666 ;6'666Bmm Bmm' E3ek E3ek s%mpi s%mpin# n# "e,u "e,up% p% %pl% %pl%si% si% sums sumsum um +ul%n +ul%n# #  "e,kep%n(%n#%n& 3i",osis p%,u& -%n "%h%*% +im"uln*% +im"uln*% leukemi% %ku+  "' Hi-,oksiu,e%$ -osis -i+i+,%si -%,i ;66=4'666 m#& kemu-i%n -i"e,ik%n -osis  pemelih%,%%n un+uk men%p%i leukosi+ 16'666=1;'666Bmm& e3ek s%mpin#n*% le"ih se-iki+ ' In+e, In+e,3e, 3e,on on %l3%$ %l3%$ "i%s% "i%s%n* n*%% -i"e -i"e,i ,ik% k%n n se+el% se+el%h h (uml (uml%h %h leuk leukos osi+ i+ +e,k +e,kon on+, +,ol ol oleh oleh hi-,oksiu,e%' -' T,%np ,%npl% l%n+ n+%s %sii sums sumsum um +ul% +ul%n# n#&& mem" mem"e, e,ik ik%n %n h%,% h%,%p% p%n n pen* pen*em em"u "uh% h%n n (%n# (%n#k% k%  p%n(%n#& +e,u+%m% un+uk pen-e,i+% *%n# "e,usi% ku,%n# -%,i :6 +%hun' !en%n#%n%n umum *%n# -i"e,ik%n %-%l%h allogeneic perip$eral bloo" stem cell  transplantation' transplantation' e' Te,%pi Te,%pi -en#%n -en#%n mem%k%i mem%k%i p,insip p,insip "iolo# "iolo#ii molekul molekule,  e,  O"%+ "%,u in%+ini" mesil%+e >#lee2e@ *%n# -%p%+ menek%n %k+i2i+%s +*,osine kin%se& sehin##% menek%n p,oli3e,%si sel m*eloi-' D L#&$ L#&$#m,a #m,a L,m+-, L,m+-, K"-n,$ K"-n,$ (LLK (LLK))

!en#o"%+%n se"%ikn*% +i-%k -i"e,ik%n p%-% klien +%np% #e(%l%& k%,en% h%l ini +i-%k  mempe, mempe,p%n p%n(%n (%n# # hi-up' hi-up' H%l *%n# *%n# pe,lu pe,lu -ih%-% -ih%-%pi pi %-%l%h %-%l%h klien klien *%n# *%n# menun( menun(ukk ukk%n %n  p,o#,esi2i+%s lim3%-enop%+i %+%u splenome#%li& %nemi%& +,om"osi+openi%& %+%u #e(%l% %ki"%+ -es%k%n +umo,' O"%+=o"%+%n *%n# pe,lu -i"e,ik%n %-%l%h s e"%#%i "e,iku+$ %' Klo,%m Klo,%m"us "usil il 6&1=6 6&1=6& & m#Bk m#Bk# # 77Bh%, 77Bh%,ii pe, o,%l o,%l  "' Ko,+ikos+e,oi- se"%ikn*% "%,u -i"e,ik%n "il% +e,-%p%+ AIHA %+%u +,om"osi+openi% %+%u -em%m +%np% sein3eksi ' R%-io+ R%-io+e,%p e,%pii -en#%n -en#%n men##un men##un%k% %k%n n sin%, sin%,  k%-%n#= k%-%n#=k%k%-%n# %n# men#un+ men#un+un# un#k%n k%n "il% %-% keluh%n pen-es%k%n k%,en% pem"en#k%k%n kelen(%, #e+%h "enin# se+emp%+' 2: P#na!ala$'anaan K##"a;a!an

Menu,u+ H%n-%*%ni G H%,i"o/o p%-% +%hun >466<@& l%n#k%h=l%n#k%h kepe,%/%+%n *%n# -%p%+ -il%kuk%n +e,h%-%p klien -en#%n leukemi% %-%l%h se"%#%i "e,iku+$ A P#n% P#n%$a $a*, *,an an 1 I-en+i3ik%si "%+%s%n +%n-%=+%n-% -%n #e(%l%=#e(%l% *%n# -il%po,k%n oleh p%sien

-%l%m ,i/%*%+ kepe,%/%+%n -%n peme,iks%%n 3isik

15

2 ?%m"%,%n klinis %k%n "e,%#%m -en#%n +ipe leukemi% *%n# +e,(%-i *%i+u kelem%h%n -%n kele+ih%n& kele+ih%n& keen-e,un# keen-e,un#%n %n pe,-%,%h%n& pe,-%,%h%n& pe+eki% -%n ekimosis& n*e,i& s%ki+ kep%l%& mun+%h& -em%m& -%n in3eksi !eme,iks%%n s%%n -%,%h -%,%h mun#ki mun#kin n menun( menun(ukk ukk%n %n pe,u"% pe,u"%h%n h%n sel=sel sel=sel -%,%h -%,%h pu+ih pu+ih -%n  !eme,ik +,om"osi+openi%' B D,a%nD,a%n-'a 'a K# K##" #"a;a a;a!an !an 7e,-%s 7e,-%s%,k %,k%n %n -%+% -%+% -%s%, -%s%, pen#k% pen#k%(i%n (i%n&& -i%#no -i%#nosis sis kepe,%/ kepe,%/%+%n %+%n *%n# *%n# munu munull %-%l%h %-%l%h

se"%#%i "e,iku+$ 1' N*e,i *%n# *%n# "e,hu"un#%n "e,hu"un#%n -en#%n in3il+,%si in3il+,%si leukosi+ (%,in#%n sis+emik 4' ?%n##u%n nu+,isi ku,%n# ku,%n# -%,i ke"u+uh%n ke"u+uh%n +u"uh *%n# *%n# "e,hu"un#%n -en#%n mu%l& mun+%h& %no,eksi%& -%n e3ek +oksik o"%+ kemo+e,%pi ' In+ole,%nsi %k+i2i+%s "e,hu"un#%n -en#%n %nemi% :' Risiko +in##i penu,un%n 2olume %i,%n "e,hu"un#%n -en#%n pe,-%,%h%n pe,-%,%h%n ;' ?%n# ?%n##u #u%n %n in+e# in+e#,i+ ,i+%s %s kuli+ kuli+$$ %lop %lopesi esi%% *%n# *%n# "e,h "e,hu" u"un un#% #%n n -en# -en#%n %n e3ek e3ek +oks +oksik  ik  kemo+e,%pi 5' ?%n##u ?%n##u%n %n #%m"%,% #%m"%,%n n -i,i -i,i "e,hu" "e,hu"un# un#%n %n -en#%n -en#%n pe,u"% pe,u"%h%n h%n pen%mp pen%mpil%n il%n -%l%m -%l%m 3un#si -%n pe,%n 9' 7e,-uk 7e,-uk%% *%n# *%n# "e,hu" "e,hu"un# un#%n %n -en#%n -en#%n kehil%n kehil%n#%n #%n kemun# kemun#kin kin%n %n +e,(%+e,(%-ii k%,en% k%,en%  pe,u"%h%n pe,%n -%n 3un#si -i,i'

4 In!#"6#n', K##"a;a!an 7e,i 7e,iku ku++ %-%l% %-%l%h h pen( pen(el el%s% %s%n n men# men#en en%i %i in+e in+e,2 ,2en ensi si -%,i -%,i m%si m%sin# n#=m% =m%sin sin# # -i%# -i%#no nos% s%

kepe,%/%+%n *%n# +el%h -i%m"il$ a D,a% D,a%nn-'a 'a $# $##" #"a; a;a! a!an an 1  N*e,i *%n# "e,hu"un#%n -en#%n in3il+,%si leukosi+ (%,in#%n sis+emik' T&*&an$ Se+el%h -il%kuk%n +in-%k%n kepe,%/%+%n n*e,i %k%n "e,ku,%n#' K",!#",a Ha',l$ 1' Mel%po,k%n penu,un%n +in#k%+ n*e,i 4' Men(el%sk%n "%#%im%n% kele+ih%n -%n ke+%ku+%n memen#%,uhi n*e,i ' Mene,im% me-ik%si n*e,i sesu%i -en#%n ,esep *%n# -i,esepk%n :' Menun(ukk%n penu,un%n +%n-%=+%n-% 3isik -%n pe,il%ku +en+%n# n*e,i ;' Men#%m"il pe,%n %k+i3 -%l%m pem"e,i%n %n%l#e+ik 5' Men#i-en+i3ik%si s+,%+e#i pe,e-%%n n*e,i 9' Men##un%k%n s+,%+e#i pe,e-%%n n*e,i -en#%n +ep%+'

In!#"6#n', Ra',-nal K%(i k%,%k+e,is+ik n*e,i$ lok%si& ku%li+%s& Mem" em"e,i e,ik%n -%s%, s%, un+uk men# en#k%(i %(i 3,ekuensi& -%n -u,%si'  pe,u"%h%n p%-% +in#k%+ n*e,i -%n men#e2%lu%si in+e,2ensi' Ten%n#k%n klien "%h/% %n-% men#e+%hui R%s% +%ku+ "%h/% n*e,in*% +i-%k -i%n##%p n*e,i *%n# -i,%s%k%nn*% %-%l%h n*%+% -%n n*%+% n*%+% -%p% -%p%++ meni menin# n#k% k%+k +k%n %n %nsi %nsie+% e+%ss -%n -%n  "%h/% %n-% %k%n mem"%n+u klien -%l%m men#u,%n#i +ole,%nsi n*e,i' 19

men#u,%n#i n*e,i +e,se"u+' K%(i 3%k+o, l%in *%n# menun(%n# n*e,i& kele+ih%n& -%n m%,%h klien'

Mem"e,i Mem"e,ik%n k%n -%+% -%+% +en+%n# +en+%n# 3%k+o, 3%k+o,=3% =3%k+o k+o,  ,  *%n# menu,unk%n kem%mpu%n klien un+uk  meno menole le,% ,%ns nsii n*e, n*e,ii -%n -%n meni menin# n#k% k%+k +k%n %n +in#k%+ n*e,i klien' 7e,ik% 7e,ik%n n %n%l#e+ %n%l#e+ik ik un+uk un+uk menin# menin#k%+ k%+k%n k%n An%l#e An%l#e+ik +ik en-e,u en-e,un# n# le"ih le"ih e3ek+i3 e3ek+i3 ke+ik% ke+ik%  pe,e-%%n n*e,i op+im%l -%l%m "%+%s ,esep ,es ep -i"e,ik%n se%,% -ini p%-% siklus n*e,i' -ok+e,' K%(i ,espon pe,il%ku klien +e,h%-%p n*e,i Mem"e,ik%n Mem"e,ik%n in3o,m%si in3o,m%si +%m"%h%n +%m"%h%n +en+%n# +en+%n# -%n pen#%l%m%n n*e,i' n*e,i klien' Kol%"o,%sik%n -en#%n klien& -ok+e,& -%n Me+o-e Me+o-e "%,u "%,u pem"e, pem"e,i%n i%n %n%l#e+ %n%l#e+ik ik h%,us h%,us +im +im pe,% pe,%/% /%+% +%n n kese keseh% h%+% +%n n l%in l%in ke+i ke+ik% k% -%p% -%p%++ -i+e -i+e,i ,im m% klie klien& n& -ok+ -ok+e, e,&& -%n -%n +im +im men#u"%h pen%+%l +%l%ks%n s%n%%n %%n n*e, n*e,ii  pe,%/%+%n keseh%+%n l%in %#%, -%p%+ -ipe,luk%n' e3ek+i3& e3ek+i3& p%,+sip%si p%,+sip%si klien menu,unk%n menu,unk%n ,%s% ke+i-%k"e,-%*%%n klien' A(%,k (%,k%%n klien s+,%+e %+e#i "%,u un+uk  Menin#k%+k%n (uml%h pilih%n -%n s+,%+e#i me,e-%k%n n*e,i$ -is+,%ksi& im%(in%si& -%n *%n# +e,se-i% "%#i klien' ,el%ks%si' 7e,ik% 7e,ik%n n -ukun# -ukun#%n %n pen##u pen##un%% n%%n n s+,%+e# s+,%+e#ii Mem"e,i Mem"e,ik%n k%n -o,on# -o,on#%n %n s+,%+e# s+,%+e#ii pe,e-% pe,e-%%n %n  pe,e-% n*e,i *%n# +el%h klien +e,%pk%n n*e, n*e,ii *%n# %n# -%p -%p%+ -i+e, i+e,im im%% klien lien -%n -%n -en#%n -en#%n "e,h%sil "e,h%sil p%-% pen#%l%m%n n*e,i kelu%,#%' se"elumn*%' . D,a% D,a%nn-'a 'a $# $##" #"a; a;a! a!an an 2 ?%n##u%n ?%n##u%n nu+,isi ku,%n# ku,%n# -%,i ke"u+uh%n +u"uh *%n# "e,hu"un# "e,hu"un#%n %n -en#%n -en#%n mu%l& mun+%h& %no,eksi%& -%n e3ek +oksik o"%+ kemo+e,%pi T&*&an8 men#u,%n#i mu%l mun+%h se"elum& sel%m%& -%n sesu-%h pem"e,i%n kemo+e,%pi K",!#",a Ha',l8 7e,iku+ ini %-%l%h h%l=h%l *%n# h%,us -il%kuk%n p%-% klien -en#%n m%s%l%h nu+,isi$ 1' Mel%po,k%n penu,un%n mu%l 4' Mel%po,k%n penu,un%n mun+%h ' Men#onsumsi %i,%n -%n m%k%n%n *%n# %-eku%+ :' Menun(ukk%n pen##un%%n -is+,%ksi& ,el%ks%si& -%n im%(in%si ke+ik% -iin-ik%sik%n ;' Menun(ukk%n +u,#o, kuli+ no,m%l -%n mem",%n mukos% *%n# le m"%" 5' Mel%po,k%n +i-%k %-%n*% penu,un%n "e,%+ "%-%n +%m"%h%n' In!#"6#n',

Ra',-nal

Sesu Sesu%i %ik% k%n n -ie+ -ie+ se"e se"elu lum m -%n -%n sesu sesu-% -%h h  pem"e,i%n o"%+ sesu%i -en#%n kesuk%%n -%n +ole,%nsi klien'

Se+i% Se+i%p p klien klien "e,e "e,esp spon on se%,% se%,% "e," "e,"ee-%% +e,h%-% +e,h%-%p p m%k%n% m%k%n%n n se+el%h se+el%h kemo+e kemo+e,%p ,%pi& i& m%k% m%k%n% n%n n kesu kesuk% k%%n %n -%p% -%p%++ me,eme,e-%k %k%n %n mu%l -%n mun+%h klien' Ce#%h p%n-%n#%n& p%n-%n#%n& "%u& -%n "un*i="un* "un*i="un*ii Sens Sens%s %sii +i-% +i-%k k men* men*en en%n %n#k #k%n %n -%p% -%p%++ *%n# +i-%k men*en%n#k%n -i lin#kun#%n' mens+imul%si pus%+ mu%l -%n mun+%h' ?un%k%n -is+,%ksi& ,el%ks%si& -%n im%(in%si Menu,un ,unk%n %nsie+%s +%s *%n# -%p% %p%+ se"elum -%n sesu-%h kemo+e,%pi' menun(%n# mu%l mun+%h' 7e,ik e,ik%n %n %n+i %n+iem eme+ e+i i&& se-% se-%+i +i2e 2e&& -%n Kom" Kom"in in%s %sii +e,% +e,%pi pi o"%+ o"%+ "e,u "e,up p%*% %*% un+u un+uk  k  18

kos+ikos+e,oi- *%n# -i,esepk%n'

men#u,%n#i mu%l mun+%h mel%lui kon+,ol  "e,"%#%i 3%k+o, pene+us' olume lume %i, %i,%n %n *%n# %n# %-ek %-eku% u%++ %k%n %k%n men#en men#ene,k e,k%n %n k%-%, k%-%, o"%+& o"%+& men#u, men#u,%n# %n#ii s+imul%si ,esep+o, mun+%h' Men# Men#u, u,%n %n# #i ,%s% ,%s% ke%p e%p *%n# %n# +i-% +i-%k  k  men*en%n#k%n'

!%s+ !%s+ik ik%n %n hi-, hi-,%s %sii %i, %i,%n %n *%n# %n# %-ek %-eku% u%++ se"elum& sel%m%& -%n sesu-%h pem"e,i%n o"%+' K%(i in+%ke -%n ou+pu+ %i,%n' 7e,ik%n -ukun#%n=-ukun#%n kep%-% klien %#%, %#%, -%p% -%p%++ men( men(%# %#%% pe,s pe,son on%l %l h*#e h*#ene ne -en#%n "%ik' 7e,ik e,ik%n %n +in+in-%k %k%n %n pe,ee,e-%% n*e, n*e,ii (ik% (ik% Menin#k%+k %+k%n ,%s ,%s% n*%m%n %m%n %k%n -ipe,luk%n' menin# menin#k%+ k%+k%n k%n +ole,%n +ole,%nsi si 3isik 3isik +e,h%-%p +e,h%-%p #e(%l% *%n# -i,%s%k%n' 3 D,a% D,a%nn-'a 'a $## $##"a "a;a ;a!a !an n In+ole,%nsi %k+i2i+%s "e,hu"un#%n -en#%n %nemi%' T&*&an8 'e+el%h -il%kuk%n +in-%k%n +e,(%-i penu,un%n +in#k%+ kele+ih%n' K",!#",a Ha',l

K,i+e,i% h%sil p%-% klien -en#%n m%s%l%h n*e,i %-%l%h "il% -i-%p%+k%n %-%n*% h%l=h%l  "e,iku+ ini$ 1' Mel%po,k%n penu,un%n +in#k%+ kele+ih%n 4' Menin#k%+n*% keiku+se,+%%n -%l%m %k+i2i+%s se%,% "e,+%h%p ' Is+i,%h%+ ke+ik% men#%l%mi kele+ih%n :' Mel%po,k%n -%p%+ +i-u, le"ih "%ik ;' Mel%po,k%n ene,#i *%n# %-eku%+ un+uk iku+ se,+% -%l%m %k+i2i+%s 5' Men#onsumsi -ie+ -en#%n m%suk%n p,o+ein -%n k%lo,i *%n# -i%n(u,k%n In!#"6#n', Ra',-nal 7e,ik e,ik%n %n -o,o o,on#%n n#%n un+u n+uk is+i is+i,% ,%h h%+ Sel% Sel%m% m% is+i is+i,% ,%h% h%+& +& ene, ene,#i #i -ihe -ihem% m%++ -%n -%n  "e"e,%p% pe,io-e sel%m% si%n# h%,i& +in#k% +in#k%++ ene,# ene,#ii -ipe," -ipe,"%,u %,ui' i' 7e"e,%p 7e"e,%p%% k%li k%li +e,u+%m +e,u+%m%% se"elu se"elum m -%n sesu-%h sesu-%h l%+ih%n l%+ih%n  pe,io-e is+i,%h%+ sin#k%+ mun#kin le"ih 3isik'  "e,m%n3%%+ -i"%n-in#k%n s%+u k%li pe,io-e is+i,%h%+ *%n# p%n(%n#' Tin#k%+k%n (%m +i-u, +o+%l p%-% m%l%m Ti-u, mem" em"%n+u %n+u un+u n+uk memul emulih ihk% k%n n h%,i' +in#k%+ ene,#i' A+u, kem"%li (%-/%l se+i%p h%,i -%n %+u,  !en# !en#%+ %+u, u,%n %n kem" kem"%l %lii %k+i %k+i2i 2i+% +%ss -%p -%p%+ %k+i2i+%s %k+i2i+%s un+uk un+uk men#hem men#hem%+ %+ pem%k%i%n pem%k%i%n men#u en#u,% ,%n n#i kehil ehil%n %n#% #%n n ene, ene,#* #* -%n -%n ene,#i' men#u,%n#i s+,esso,' 7e,ik 7e,ik%n %n m%su m%suk% k%n n p,o+ p,o+ein ein -%n -%n k%lo k%lo,i ,i !enipis%n k%lo,i -%n p,o+ein menu,unk%n *%n# %-eku%+' +ole,%nsi %k+i2i+%s' 7e,ik%n -o,on#%n un+uk +eknik  !eni !enin n#k%+ #k%+%n %n ,el% ,el%k ks%si s%si -%n is+i is+i,% ,%h h%+ ,el%ks%si'  psikolo#is -%p%+ menu,unk%n kele+ih%n 3isik' Kol% Kol%"o "o,%s ,%sii pem"e, pem"e,i% i%n n p,op,o-uk uk -%,%h -%,%h !enu,un%n hemo#lo"in %k%n mene+usk%n sesu%i *%n# -i,esepk%n' klie klien n p%-% p%-% kele kele+ih +ih%n %n %ki"% %ki"%++ penu penu,u ,un% n%n n ke+e,se-i%%n oksi#en'

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 D,a% D,a%nn-'a 'a $# $##" #"a; a;a! a!an an 5 Ak+u%lB Ak+u%lB,is ,isiko iko +in##i +in##i penu,u penu,un%n n%n 2olume 2olume %i,%n %i,%n "e,hu" "e,hu"un# un#%n %n -en#%n -en#%n pen#el pen#elu%, u%,%n %n

 "e,le"ih%n sepe,+i mun+%h -%n pe,-%,%h%n T&*&an8 -%l%m /%k+u 14: (%m #%n##u%n 2olume %i,%n -%p%+ +e,%+%si K",!# K",!#",a ",a Ha',l8 Ha',l8 klien +i-%k men#eluh pusin#& mem",%n mukos% lem"%"& +u,#o, kuli+

no,m%l no,m%l&& -%n +%n-%= +%n-%=+%n +%n-% -% 2i+%l 2i+%l -%l%m -%l%m "%+%s "%+%s no,m%l no,m%l'' L%"o,%+ L%"o,%+o,i o,ium$ um$ nil%i nil%i hem%+ok hem%+ok,i+ ,i+ menin#k%+' In+e,2ensi *%n# -%p%+ -il%kuk%n %n+%,% l%in$ In!#"6#n', !%n+%u s+%+us %i,%n >+u,#o, kuli+& mem",%n mukos%@ K%(i sum"e,=sum"e, kehil%n#%n

Ra',-nal Juml%h -%n +ipe %i,%n pen##%n+i -i+en+uk%n -%,i ke%-%%n s+%+us %i,%n !e,-%,%h%n h%,us -iken-%lik%n& mun+%h -%p%+ -i%+%si -en#%n o"%+=o"%+ %n+ieme+ik  Auskul+%si TD Hipo+ensi -%p%+ +e,(%-i p%-% hipo2olemi *%n# %n# mem mem"e,i "e,ik k%n m%ni m%ni3e 3es+ s+%s %sii su-% su-%h h +e,li"% +e,li"%+n* +n*%% sis+em sis+em k%,-io k%,-io2%s 2%skul kul%, %, un+uk  un+uk  mel%kuk%n mel%kuk%n kompens%si kompens%si mempe,+%h%n mempe,+%h%nk%n k%n +ek%n%n -%,%h K%(i /%,n% kuli+& suhu& si%nosis& -%n n%-i Men# Men#e+ e+%h %hui ui %-%n %-%n* *% pen# pen#%, %,uh uh %-%n %-%n* *%  pe,i3e,   penin#k%+%n +%h%n%n pe,i3e,  Kol%"o,%si$ !e,+ !e,+%h %h%n %nk% k%n n pem" pem"e, e,i% i%n n %i, %i,%n %n se% se%,% ,% J%lu, *%n# p%+en pen+in# un+uk pem"e,i%n in+,% in+,%2e 2en% n%&& (ik% (ik% memu memun# n#ki kink nk%n %n "e,ik "e,ik%n %n %i,% %i,%n n ep% ep%++ -%n -%n memu memu-% -%hk hk%n %n pe,%/ pe,%/%+ %+  p,o-uk -%,%h sesu%i *%n# -i,esepk%n -%l%m mel%kuk%n on+,ol in+%ke -%n ou+pu+ %i,%n Moni Moni+o +o,, h%sil h%sil peme peme,i ,iks ks%%n %%n -i%# -i%#no nos+i s+ik$ k$ 7il% pl%+ele+ P46'666Bmm klien en-e,un#  pl%+ele+& H"BH+& -%n "eku%n -%,%h men#%l%mi pe,-%,%h%n' !enu,un%n H"BH+  "e,in-ik%si +e,h%-%p pe,-%,%h%n # D,a% D,a%nn-'a 'a $## $##"a "a;a ;a!a !an n7 7e,-uk 7e,-uk%% *%n# *%n# "e,hu" "e,hu"un# un#%n %n -en#%n -en#%n kehil% kehil%n#% n#%n& n& kemun kemun#ki #kin%n n%n +e,(%-i +e,(%-i k%,en% k%,en%

 pe,u"%h%n pe,%n 3un#si' T&*&an8 klien m%mpu mele/%+i p,oses "e,-uk% -en#%n sesu%i' K",!#",a Ha',l8 1 Klien -%n kelu%,#% %k%n "e,kem"%n# mel%lui 3%se=3%se +e,"uk% Klien n -%n -%n kelu kelu%, %,#% #% men# men#ii-en en+i +i3ik 3ik%si %si sum" sum"e, e, sum" sum"e, e, *%n# *%n# +e,se +e,se-i -i%% un+u un+uk  k  2 Klie mem"%n+u s+,%+e#i kopin# sel%m% "e,-uk%  Klien -%n kelu%,#% men##un%k%n sum"e, = sum"e, -%n -ukun#%n se%,% sesu%i 5 Klien -%n kelu%,#% men-iskusik%n kekh%/%+i,%n -%n pe,%s%%n se%,% +e,"uk% s%+u s%m% l%in 7 Klien -%n kelu%,#% men##un%k%n eksp,esi non2e,"%l +en+%n# kekh%/%+i,%n me,ek% +e,h%-%p s%+u s%m% l%in' 46

In+e,2ensi kepe,%/%+%n p%-% klien ini "e,+u(u%n %#%, klien m%mpu men##un%k%n kopin# *%n# e3ek+i3 un+uk men#%+%si pe,%s%%n -uk% *%n# -ih%-%pin*%' In!#"6#n', 7%n+ %n+u klien un+uk men#un#k%pk%n ke+%ku ke+%ku+%n +%n&& kekh%/ kekh%/%+i %+i,%n& ,%n& -%n pe,+%n* pe,+%n*%%n %%n +en+%n# pen*%ki %ki+& pen#o"%+%n& se, se,+% implik%sin*% -i m%s% *%n# %k%n -%+%n#' 7e,ik%n -ukun#%n p%,+isip%si %k+i3 -%,i klien -%n kelu%,#%n*% -%l%m kepu+us%n pe,%/%+%n -%n pen#o"%+%n' 7e,i e,ik%n -ukun#%n %#% %#%, klien -%p%+ mem"u%n# pe,%s%%n ne#%+i3'

Ra',-nal D%s% D%s%,, pen# pen#e+ e+%h %hu u%n *%n# %n# %ku, %ku,%+ %+ -%n -%n menin#k%+ %k%n men#u,%n#i %nsie+%s -%n melu,ussk%n miskonsepsin*%'

!%,+ !%,+isi isip% p%si si %k+i %k+i33 %k%n %k%n memp mempe,+ e,+%h %h%n %nk% k%n n kem%n-i,i%n -%n on+,ol emosi klien'

H%l ini memun#kink%n un+uk   men#eksp eksp,,esi esik%n emosion%l +%np% kehil%n#%n h%,#% -i,i' 7e,ik% 7e,ik%n n /%k+u /%k+u un+uk un+uk klien klien men%n# men%n#is is -%n !e,%s%%n ini -i pe,luk%n un+uk +e,(%-in*% men#eksp,esik%n kese-ih%nn*%'  pe,pis%h%nn -%n ke,en##%n#%n ' Li"%+ i"%+k% k%n n pe+u# e+u#%s %s sesu sesu%i %i -en -en#%n #%n *%n# %n# ?un% ?un% mem3%si mem3%sili+% li+%si si p,oses p,oses "e,-uk "e,-uk%% -%n -iin#ink%n oleh klien -%n kelu%,#%'  pe,%/%+%n spi,i+u%l' S%,%nk%n konselin# p,o3ession%l sesu%i *%n# H%l ini mem3%sili+%si p,oses "e,-uk% -iin-i -iin-ik%s k%sik% ik%n n "%#i "%#i klien klien -%n kelu%, kelu%,#%n #%n*% *% un+uk men#hil%n#k%n p,oses "e,-uk% *%n#  p%+olo#is' Cip+%k%n si+u%si *%n# memun#kink%n un+uk  !,oses "e,-uk% "e,%#%m' Oleh k%,en% i+u  "e,%lih mele/%+i p,oses "e,-uk%' un+u un+uk k men* men*ele eles%i s%ik% k%n n p,os p,oses es "e,"e,-uk uk%& %& ke"e,%#%m%n ini h%,us -i "i%,k%n +e,(%-i'

+ D,a% D,a%nn-'a 'a $# $##" #"a; a;a! a!an an 9

?%n##u%n in+e#,i+%s kuli+$ %lopesi% *%n# "e,hu"un#%n -en#%n e3ek +oksik kemo+e,%pi' T&*&an8 T& *&an8 se+el%h -il%kuk%n -il%kuk%n +in-%k%n +in-%k%n kepe,%/%+%n& kepe,%/%+%n& m%k% #%n##u%n #%n##u%n in+e#,i+%s kuli+ +i-%k 

+e,(%-i' K",!#",a Ha',l8 Tin-%k%n Tin-%k%n kepe,%/%+%n *%n# -il%kuk%n -il%kuk%n -ik%+%k%n -ik%+%k%n "e,h%sil "e,h%sil (ik% -%p%+ memenuhi k,i+e,i% k,i+e,i%

 "e,iku+ ini' 1'Men#i-en+i3ik%si %lopesi% se"%#%i po+ensi%l e3ek s%mpin# -%n pen#o"%+%n 4'Men#i-en+i3ik%si pe,%s%%n ne#%+i2e -%n posi+i3 se,+% %n%m%n +e,h%-%p i+,% -i,i 'Men#un#k%pk%n men#en%i %-%n*% kemun#kin%n ke,on+ok%n ,%m"u+ *%n# -imiliki :'Men*e"u+k%n ,%sion%l un+uk mo-i3ik%si -%l%m pe,%/%+%n ,%m"u+ -%n pen#o"%+%n ;'Mel%kuk%n l%n#k%h=l%n#k%h un+uk men#%+%si kemun#kin%n ke,on+ok%n ,%m"u+'

41

In+e,2ensi kepe,%/%+%n p%-% klien -en#%n m%s%l%h #%n##u%n in+e#,i+%s kuli+ %-%l%h %#%,  m%s%l%h #%n##u%n in+e#,i+%s kuli+ p%-% klien -%p%+ +e,%+%si' In!#"6#n', Ra',-nal Diskusik%n po+ensi%l ke,on+ok%n ,%m"u+ Mem"e,i Mem"e,ik%n k%n in3o,m in3o,m%si& %si& sehin# sehin##% #% klien klien -%n pe,+u e,+um" m"uh uh%n %n kem kem"%li "%li ,%m ,%m"u+ -%n -%n kelu kelu%, %,#% #%n* n*%% -%p% -%p%++ mul% mul%ii un+u un+uk  k   "e,s%m% klien -%n kelu%,#%'  "e,si%p -i,i se%,% ko#ni+i3 -%n emosion%l +e,h%-%p ke,on+ok%n' Ce#%h %+%u minim%lk%n -%mp%k  Meminim%lk%n ke,on+ok%n ,%m"u+ %ki"%+ ke,o ke,on+ n+ok ok%n %n ,%m" ,%m"u+ u+ mel%l mel%lui ui l%n#k l%n#k%h %h==  "e"%n "e,%+ -%n +%,ik%n p%-% ,%m"u+' l%n#k%h "e,iku+ ini' %' !o+on# ,%m"u+ *%n# p%n(%n# se"elum pen#o"%+%n'  "' Hin-%,i pem%k%i%n sh%mpoo *%n#  "e,le"ih%n' ' Men Men##un ##un%k %k%n %n sh%m sh%mp poo ,in# ,in#%n %n -%n on-i+ione,' -' HinHin-%,i %,i pen## pen##un un%%n %%n pen#e pen#e,i+ ,i+in in# # lis+,ik& pem%n%s& pen#e,in ,in# ,%m"u+& -%n pen(epi+' e' Hin-%,i %,i men* en*isi, si, "e,le" le"ih%n& #un% #un%k% k%n n sisi sisi,, *%n# *%n# "e,# "e,#e, e,i# i#ii le"%,' Ce#%h +,%um% p%-% kuli+ kep%l%' Mem"%n+u -%l%m mempe,+%h%nk%n  pe,+um"uh%n ,%m"u+' S%,%nk S%,%nk%n %n %,% un+uk un+uk mem"%n mem"%n+u +u -%l%m -%l%m Men*%m%,k%n ke,on+ok%n ,%m"u+' men# men#%+% %+%si si ke,o ke,on+ n+ok ok%n %n ,%m"u ,%m"u++ sepe sepe,+i ,+i men#en%k%n /ik %+%u mem%k%i +opi' Jel%s Jel%sk% k%n n "%h/ "%h/%% pe,+ pe,+um um"u "uh% h%n n ,%m" ,%m"u+ u+ Menen% Menen%n#k n#k%n %n klien klien "%h/% "%h/% ke,on+ ke,on+ok% ok%n n  "i%s%n*% mul%i kem"%li ke+ik% ,%m"u+ "i%s%n*% "e,si3%+ semen+%,%'  pen#o"%+%n +el%h seles%i'

% D,a% D,a%nn-'a 'a $# $##" #"a; a;a! a!an an :

?%n##u%n #%m"%,%n -i,i *%n# "e,hu"un#%n -en#%n pe,u"%h%n pen%mpil%n& 3un#si& -%n pe,%n' T&*&an8 T& *&an8 se+el%h -il%kuk%n pem"e,i%n %suh%n kepe,%/%+%n&m%k% i+,% +u"uh -%n h%,#%

-i,i klien -%p%+ -ipe,"%iki' K",!#",a Ha',l8

K,i+e,i% h%sil p%-% klien ini %-%l%h$ 1' Men#iMen#i-en+ en+i3ik i3ik%si %si h%l h%l h%l h%l *%n# *%n# pen+in pen+in# # 4' Men#%m Men#%m"il "il pe,%n pe,%n %k+i3 %k+i3 -%l%m -%l%m %k+i %k+i2i+% 2i+%s s ' Mempe,+%h%n Mempe,+%h%nk%n k%n pe,%n pe,%n se"elum se"elumn*% n*% -%l%m -%l%m pem"u%+ pem"u%+%n %n kepu+us%n kepu+us%n 44

:' Men#un#k%p Men#un#k%pk%n k%n pe,%s%%n -%n ,e%ksi +e,h%-%p +e,h%-%p kehil%n kehil%n#%n #%n ;' Iku+ Iku+ se,+% se,+% -%l%m -%l%m %k+i2 %k+i2i+% i+%ss pe,%/%+ pe,%/%+%n %n -i,i' -i,i' In+e,2e In+e,2ensi nsi kepe,% kepe,%/%+ /%+%n %n *%n# *%n# -i"e,ik -i"e,ik%n %n p%-% p%-% klien klien -en#%n -en#%n #%n##u #%n##u%n %n #%m"%,% #%m"%,%n n -i,i -i,i  "e,+u(u%n %#%, +e,%p%i penin#k%+%n h%,#% -i,i' In!#"6#n', Ra',-nal K%(i pe,%s%%n klien +en+%n# #%m"%,%n -%n Se+i%p i%p klien ien "e,espo spons se% e%,% +in#k%+ h%,#% -i,i'  "e,"e-% +e,h%-%p m%k%n%n se+el%h kemo+e,%pi&m%k%n%n kesuk%%n -%p%+ me,e-%k%n mu%l mun+%h klien' 7e,ik%n mo+i2%si un+uk keiku+se,+%%n *%n# Mem"e,ik%n mo+i2%si kon+ kon+in inu u -%l%m -%l%m %k+i2 %k+i2i+ i+%s %s -%n -%n pem" pem"u% u%+%n +%n memu memun# n#ki kink nk%n %n on+ on+,o ,oll kon+ kon+in inu u kepu+us%n' +e,h%-%p ke(%-i%n -%n -i,i klien' 7e,ik%n k%n -ukun#%n p%-% klien ien un+uk  Men# Men#ii-en en+i +i3i 3ik% k%si si kekh kekh%/ %/%+ %+i, i,%n %n men#un#k%pk%n kekh%/%+i,%nn*%' me,u me,up% p%k% k%n n s%+u s%+u +%h% +%h%p% p%n n pen+ pen+in in# # -%l%m men#%+%sin*%' 7%n+ 7%n+u u klie klien n -%l%m -%l%m pe,%/ pe,%/%+% %+%n n -i,i -i,i ke+i ke+ik% k% Kese(%h+ Kese(%h+e,% e,%%n %n 3isik 3isik menin# menin#k%+ k%+k%n k%n kele+ih%n' h%,#% -i,i' 7e,ik%n mo+i2%si kep%-% klien -%n Mem Mem"e,i "e,ik k%n kese kesem mp%+% p%+%n n un+u un+uk  k   p%s%n#%nn*% un+uk s%lin# "e,"%#i men#eksp,esik%n kekh%/%+i,%nn*%' kekh%/ kekh%/%+i, %+i,%n %n men#en men#en%i %i pe,u"% pe,u"%h%n h%n 3un#si 3un#si seksu%l'

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1' 4'

Alopesi%$ Ke"o+%k%n& ke,on+ok%n ,%m"u+' Apl%si%$ !e,kem"%n#%n (%,in#%n *%n# +i-%k  

len#k%p %+%u ke%-%%n +i-%k %-%n*% pe,+um"uh%n' ' Asimp+om%+ik$

Su Su%+u

pe pen*%ki+

-i -im%n%

 p%sien +i-%k men*%-%,i #e(%l% %p%pun' :'

Di3e,ensi%si sel$ Su%+u sel men(%-i khusus -%l%m s+,uk+u, -%n 3un#sin*%'

;' 5'

Ekimosis$ Mem%, spon+%n' Eks+,%me-ul%,$ Te,le+%k %+%u

+e,(%-i

-i

se"el%h lu%, me-ull%' 9'

Epis+%ksis$ !e,-%,%h%n hi-un#' !e,-%,%h%n -%,i hi-un# "i%s%n*% %ki"%+ pe%hn*% pem"uluh -%,%h keil *%n# +e,le+%k -i "%#i%n %n+e,io, sep+um n%s%l k%,+il%#inos%'

8'

E,i+,oleukemi%$

Disk,%si%

m%li#n%

p%-%

-%,%h& s%l%h s%+u kel%in%n mielop,oli3e,%+i3 -en#%n e,i+,o"l%s %+ipik -%l%m -%,%h +epi' <' Hem%+opoie+ik$ Ke#%#%l%n -%,i  pem"en+uk%n -%,%h' 16'

Hep%+ome#%li$ !em"es%,%n h%+i' 4

11'

He,peso+e,$ Me,up%k%n m%ni3es+%si lok%l ,e%k+i2 ,e%k+i2%si %si in3eks in3eksii 2i,us 2i,us 2%,ise 2%,isel%o l%os+e, s+e, *%n# *%n# men(%men(%-ii pen*e pen*e"%" "%" pen*% pen*%ki+ ki+ %%, %%, %i,& %i,&

in3eksi ini -i+%n-%i oleh ,u%m 2esikule, 2esikule, -i -%e,%h -is+,i"usi s%,%3 senso,ik' 14' Hipe,+,o3i #usi$ !em"es%,%n

%+%u

 pe,+um"uh%n "e,le"ih%n -%,i #usi %ki"%+ penin#k%+%n penin#k%+%n uku,%n sel sel pem"en+ukn*%' 1' Hipe,u,isemi%$ Kele"ih%n %s%m u,%+ -%l%m -%,%h' 1:'

Imuno3eno+ipe$

Feno+ip

sel

neopl%sm%

hem%+opoie+ik *%n# -i-e3enisik%n "e,-%s%,k%n kemi,ip%nn*% -en#%n sel T -%n sel 7' 1;' In3il+,%si$ Di3usi %+%u penim"un%n su"s+%nsi *%n# se%,% no,m%l +i-%k +e,-%p%+ p%-% sel %+%u (%,in#%n %+%u -%l%m (uml%h *%n# mele"ihi no,m%l -%l%m sel %+%u (%,in#%n +e,se"u+' 15' Leukosi+osis$ !enin#k%+%n sel -%,%h pu+ih >leukosi+@ -%l%m si,kul%si' 19'

Lim3%-enop%+i$

!e !em"es%,%n

limp% se"%#%i ,espon +e,h%-%p p,oli3e,%si lim3osi+ T %+%u lim3osi+ 7' 18' Mieloplo,i3el%+i3$ 7e 7e,k%i+%n

no no,m%l

-% -%,i

-e -en#%n %+%u

-i+%n-i+%n-%i %i -en#%n -en#%n p,oli3e p,oli3e,%si ,%si me-ul%, me-ul%,is is -%n eks+,%m eks+,%me-u e-ul%,i l%,iss unsu,= unsu,=uns unsu, u, sumsum sumsum +ul%n#' 1<'

Neopl%s+ik$

7e,hu"un#%n

-en#%n

 pem"en+uk%n neopl%sm% %+%u "e,hu "un#%n "un#%n -en#%n neopl%si%' 46' No-ul$ Ton(ol%n %+%u no-us keil *%n# p%-%+ -%n -%p%+ -iken%li mel%lui sen+uh%n' 41'

!,i%pismus$ E,eksi penis *%n# pe,sis+en -%n

%"no,m%l& -ise,+%i ,%s% n*e,i -%n n*e,i +ek%n' 44' !,o-,om%l$ ?e(%l% *%n# munul se"elum +%n-%=+%n-% se"en%,n*% *%n# me,up%k%n pe+un(uk -i%#nos+ik se "u%h pen*%ki+' 4' !,oli3 !,oli3e,%s e,%si$ i$ !e,"%n !e,"%n*%k *%k%n %n sel *%n# *%n# +e,(%-i +e,(%-i -en#%n -en#%n ep%+& ep%+& sepe,+i sepe,+i p%-% p%-% pe,+um pe,+um"uh "uh%n %n m%li#n%n >+umo, #%n%s@ -%n sel%m% kesem"uh%n luk%' 4:' !,ominen$ !%-% %n%+om& is+il%h ini "e,%,+i +on(ol%n *%n# "i%s%n*% +e,(%-i p%-% +ul%n#' 4;' !,u,i+us$ I,i+%si he"%+ p%-% kuli+' Ke%-%%n ini -%p%+ -%p%+ men#en men#en%i %i selu,uh selu,uh pe,muk pe,muk%%n %%n +u"uh +u"uh sepe,+i sepe,+i p%-% p%-% pen*%k pen*%ki+ i+ kuli+ kuli+ -%n s%,%3  s%,%3  +e,+en+u& %+%u -%p%+ pul% +e,"%+%s p%-% su%+u -%e,%h& khususn*% -%e,%h %nus -%n 2ul2%' 45' !u,pu,%$ Su%+u ke%-%%n *%n# -i+%n-%i oleh eks+,%2%s%si -%,%h ke -%l%m kuli+ -%n mem",%n mukos% *%n# men*e"%"k%n "in+ik=  "in+ik se,+% "e,%k="e,%k "e,/%,n% un#u' 49' Sel  Blast $ Sel Sel #,%n #,%nul ulos osi+ i+ *%n# *%n# imm% imm%+u +u,e ,e >"elum m%+%n#@' 4:

48' 4<'

Splenome#%li$ !em"es%,%n limp%' T,om"osi+openi%$ 7e,ku,%n#n*%

k%-%,  

+,om"osi+ se%,% -,%s+is -i -%l%m -%,%h'

P#"!anaan8

1' 4' ' :'

Ap%k%h Ap%k%h *%n# *%n# men* men*e"%" e"%"k%n k%n leukem leukemi% i% 7%#%im%n% 7%#%im%n% p,oses p,oses pen#h% pen#h%sil%n sil%n sel=sel sel=sel -%,%h -i -%l%m -%l%m +u"uh +u"uh Ap%k%h leukemi% leukemi% me,up%k me,up%k%n %n pen*%k pen*%ki+ i+ *%n# *%n# menul%, menul%, 7%#%im%n% 7%#%im%n% in+e,2ensi in+e,2ensi p%-% p%sien -en#%n -en#%n leukem leukemi% i%

4;

BAB III TINJAUAN KASUS

1 U"a,an U"a,an Ka'&' Ka'&' Tn' Q "e,usi% 49 +%hun -%+%n# ke Rum%h S%ki+ -en#%n keluh%n -em%m& lem%h& +i-%k 

 "e,+en%#% -%n n%3su m%k%n menu,un -ise,+%i mu%l -%n mun+%h' Keluh%n +e,se"u+ -i,%s%k%n se(%k ; "ul%n +e,%khi, se"elum m%suk ,um%h s%ki+& %khi,=%khi, ini se,in# -ise,+%i -en#%n suk%  pin#s%n' S%%+ peme,iks%%n& -i-%p%+k%n kon-isi klien pu%+& kon(un#+i2% %nemis& lem%h&  pusin#& "e,kun%n# s%%+ "e,-i,i& n%3su m%k%n menu,un& p%-% p%lp%si %"-omen +e,-%p%+ hep%+ome#%li -%n splenome#%li& +u,#o, kuli+ "u,uk' H%sil peme,iks%%n TT -%n l%"o,%+o,ium -i-%p%+k%n& TD$ 116B96 mmH#& N$ 168Bi& S$ 8&; 6 C& RR$ 18Bi& H"$ <& #B-L >N$ 1&;=19&; #B-L@ -L@&

Leukosi+ si+$

4:666Bmm 

>5666=11666Bmm@&

T,om"osi+ si+$

166'666

>1; >1;6'666=

:66'666Bmm@'

2 P#n%$a*, P#n%$a*,an an A Da!a S&.*#$!,+8 1' Klien men#%+%k%n "%-%nn*% +e,%s% lem%h 4' Klien men#%+%k%n +i-%k n%3su m%k%n ' Klien men#%+%k%n mu%l -%n mun+%h :' Kilen men#%+%k%n pusin# ;' Klien men#%+%k%n "e,kun%n# s%%+ "e,-i,i B Da!a Da!a O. O.*# *#$! $!,+ ,+88 1' Klien Klien +e,lih%+ +e,lih%+ pu%+& pu%+& kon(un#+ kon(un#+i2% i2% %nemis& %nemis& lem%h& pusin#& pusin#& "e,kun% "e,kun%n# n# s%%+ "e,-i,i "e,-i,i&& -%n

n%3su m%k%n menu,un 4' !%-% p%lp%si p%lp%si %"-omen %"-omen +e,-%p%+ +e,-%p%+ hep%+ome#%l hep%+ome#%lii -%n splenome#%l splenome#%li& i& +u,#o, +u,#o, kuli+ "u,uk  "u,uk  ' T%n-%= %n-%=+%n +%n-% -% 2i+%l -%n l%"o,%+o l%"o,%+o,iu ,ium m -i-%p% -i-%p%+k% +k%n n & TD$ 116B9 116B96 6 mmH#& mmH#& N$ 168BI 168BI&& S$ 8&;6 C& RR$ 18Bi& 18Bi& H"$ <& #B-L >N $ 1&;=19&; 1&;=19&; #B-L@& Leukosi+$ Leukosi+$ 4:666Bmm  >5666= 11666Bmm@& T,om"osi+$ 166'666 >1;6'666=:66'666Bmm >1;6'666=:66'666Bmm @'

 Anal,'a Anal,'a Da!a

45

N 1'

Da!a

DS$ DS$ = Klie Klien n men men#% #%+% +%k k%n "%-%n %-%nn* n*%% +e,%s% lem%h' = Klien men#%+%k%n +i-%k n%3su m%k%n' = Klien men#%+%k%n mu%l -%n mun+%h' DO$ = Klien +%mp%k #elis%h' = Klien +%mp%k pu%+ -%n lem%h' = Tu,#o, kuli+ (elek' = Mukos% "i"i, ke,in#' = 77 %/%l ;; k#' = 77 sek%,%n# :< k#' = T7 156 m' =Hep%+ome#%li =Splenome#%li = S$ 8&;6 C = H"$ <& #B-L = Leukosi+$ 4:666Bmm 

E!,-l-%,

!,oli3e,%si sel k%nke, 

Sel k%nke, "e,s%in# -en#%n sel no,m%l un+uk men-%p%+k%n nu+,isi

Ma'ala K##"a;a!an ?%n##u%n nu+,isi ku,%n# -%,i ke"u+uh%n +u"uh

In3il+,%si

Sel no,m%l -i#%n+i -en#%n sel k%nke, 

In3il+,%si Eks+,%me-ul%, >Limp% G H%+i@

Splenome#%li G He %+ome %li

Men-es%k L%m"un#

Ano,eksi%& mu%l -%n mun+%h

Gan%%&an n&!",', $&"an% a", $#.&!&an !&.&

4'

DS$ DS$ = Klie Klien n men#% en#%+% +%k k%n pusin# sin#'' = Klien men#%+%k%n  "%-%nn*% lem%h' = Klien men#%+%k%n  "e,kun%n# s%%+ "e,-i,i' = Klien men#%+%k%n men#%l%mi +%n-%=+%n-% ini se(%k ; "ul%n +e,%khi,' DO$ = Klien +%mp%k lem%h' = Klien +%mp%k pu%+' = Klien +%mp%k %nemis' = Ak+i2i+%s klien +%mp%k -i"%n+u' = H7 <& #B-L = S$ 8&;6 C = Leukosi+ 4:666Bmm '

!,oli3e,%si sel k%nke, 

In+ole,%nsi %k+i2i+%s

Sel k%nke, "e,s%in# -en#%n sel no,m%l un+uk men-%p%+k%n nu+,isi

In3il+,%si Akumul%si

In3il+,%si

Sel k%nke, "e,s%in# Sel-en#%n no,m%l sel -i#%n+i no,m%l -en#%n un+u un+uk ksel menmek%nke,  n-%% %+k% %+k%n n !,oli3e,%si sel k%nke,  sumsum +ul%n#

49

5 A'&an A'&an K##"a;a!an K##"a;a!an D,a%n-'a 18 !e,u"%h%n nu+,isi ku,%n# -%,i ke"u+uh%n +u"uh *%n# "e,hu"un#%n -en#%n m%l%ise& %no,eksi%& mu%l& -%n mun+%h' T&*&an8 Men#u,%n#i mu%l -%n mun+%h Mel%po,k%n penu,un%n penu,un%n mu%l mu%l K",!#",a Ha',l8 1' Mel%po,k%n 4' Mel%po,k%n penu,un%n mun+%h ' Men#onsumsi %i,%n -%n m%k%n%n *%n# %-eku%+ % -eku%+ :' Menun(ukk%n pen##un%%n -is+,%ksi& ,el%ks%si& -%n im%(in%si ke+ik% -iin-ik%sik%n ;' Menun(ukk%n +u,#o, kuli+ no,m%l -%n mem",%n mukos% *%n# lem"%" 5' Mel%po,k%n +i-%k %-%n*% penu,un%n "e,%+ "%-%n +%m"%h%n' Sesu%ik%n -ie+ se"elum -%n sesu-%h Se+i Se+i%p %p klie klien n "e,e "e,esp spon on se% se%,% ,% "e," "e,"ee-%%  pem"e,i%n o"%+ sesu%i -en#%n kesuk%%n +e,h +e,h%%-%p %p m%k%n m%k%n%n %n se+el% se+el%h h kemo kemo+e +e,%p ,%pi& i& -%n +ole,%nsi klien' m%k%n%n kesuk%%n -%p%+ me,e-%k%n mu%l -%n mun+%h klien' Ce#%h p%n-%n#%n& "%u& -%n "un*i="un*i Sens%si +i-%k men* en*en% en%n#k%n -%p%+ *%n# +i-%k men*en%n#k%n -i lin#kun#%n' mens+imul%si pus%+ mu%l -%n mun+%h' ?un%k%n -is+,%ksi& ,el%ks%si& -%n im%(in%si Menu,unk%n %nsie+%s *%n# -%p%+ se"elum -%n sesu-%h kemo+e,%pi' menun(%n# mu%l mun+%h' 7e,ik%n %n+ieme+ik& se-%+i3& -%n Kom" Kom"in in%s %sii +e,%p +e,%pii o"%+ o"%+ "e,u "e,up% p%*% *% un+u un+uk  k  kos+ikos+e,oi- *%n# -i,esepk%n' men#u,%n#i mu%l mun+%h mel%lui kon+,ol  "e,"%#%i 3%k+o, pene+us' !%s+ik%n hi-,%si %i,%n *%n# %-eku%+ olume %i,%n *%n# %-eku%+ %k%n se"elum& sel%m%& -%n sesu-%h pem"e,i%n men# men#en ene, e,k% k%n n k%-% k%-%,, o"%+ o"%+&& men# men#u, u,%n %n#i #i o"%+' K%(i in+%ke -%n ou+pu+ %i,%n' s+imul%si ,esep+o, mun+%h' 7e,ik%n -ukun#%n=-ukun#%n kep%-% klien Men#u,%n#i ,%s% ke% e%p *%n# %n# +i+i-%k  %#%, -%p%+ men(%#% pe,son%l h*#ene men*en%n#k%n' -en#%n "%ik' 7e,ik ,ik%n +in-%k%n pe,e-% n*e,i (ik% Menin#k%+k%n ,%s% n*%m%n %k%n -ipe,luk%n' meni menin# n#k% k%+k +k%n %n +ole +ole,%n ,%nsi si 3isik 3isik +e,h +e,h%%-%p %p #e(%l% *%n# -i,%s%k%n'

D,a%n-'a 28 In+ole,%nsi %k+i2i+%s "e,hu"un#%n -en#%n %nemi% T&*&an8 Se+el%h -il%kuk%n +in-%k%n +e,(%-i penu,un%n +in#k%+ kele+ih%n' K",!#",a Ha',l8 1' Mel%po,k%n penu,un%n +in#k%+ kele+ih%n 4' Menin#k%+n*% keiku+se,+%%n -%l%m %k+i2i+%s se%,% "e,+%h%p ' Is+i,%h%+ ke+ik% men#%l%mi kele+ih%n :' Mel%po,k%n -%p%+ +i-u, le"ih "%ik ;' Mel%po,k%n ene,#i *%n# %-eku%+ un+uk iku+ se,+% -%l%m %k+i2i+%s 5'Me 5'Men# n#on onsu sums msii -ie+ -ie+ -en# -en#%n %n m%su m%suk% k%n n p,o+ p,o+ei ein n -%n -%n k%lo k%lo,i ,i *%n# *%n# -i%n(u,k%n 7e,ik%n -o,on#%n un+uk is+i,%h%+ "e"e,%p% Sel% Sel%m m% is+i is+i,% ,%h% h%+& +& ene, ene,#i #i -ihe -ihem% m%++ -%n -%n  pe,io-e sel%m% si%n# h%,i& +e,u+%m% +in#k% +in#k%++ ene,#i ene,#i -ipe," -ipe,"%,u %,ui' i' 7e"e,%p 7e"e,%p%% k%li k%li 48

se"elum -%n sesu-%h l%+ih%n 3isik'

Tin# Tin#k% k%+k +k%n %n (%m +i-u +i-u,, +o+%l +o+%l p%-% p%-% m%l%m m%l%m h%,i' A+u, kem"%li (%-/%l se+i%p h%,i -%n %+u,  %k+i2i+ %k+i2i+%s %s un+u un+uk k men#h men#hem%+ em%+ pem%k%i pem%k%i%n %n ene,#i' 7e,ik%n m%suk%n p,o+ein -%n k%lo,i *%n# %-eku%+' 7e,ik%n 7e,ik%n -o,on# -o,on#%n %n un+uk un+uk +eknik +eknik ,el%ks% ,el%ks%si si im%(in%si' Kol%"o,%si Kol%"o,%si pem"e,i%n pem"e,i%n p,o-uk p,o-uk -%,%h sesu%i *%n# -i,esepk%n'

pe,io-e is+i,%h%+ sin#k%+ mun#kin le"ih  "e,m%n3%%+ -i"%n-in#k%n s%+u k%li pe,io-e is+i,%h%+ *%n# p%n(%n#' Ti-u, mem"%n+u un+uk memulihk%n +in#k%+ ene,#i' !en !en#%+u #%+u,% ,%n n kem kem"%li "%li %k+i %k+i2i 2i+% +%ss -%p% -%p%++ men# en#u,%n u,%n# #i kehil ehil%n %n#% #%n n ene, ene,#* #* -%n men#u,%n#i s+,esso,' !enipis%n !enipis%n k%lo,i k%lo,i -%n p,o+ein p,o+ein menu,unk%n menu,unk%n +ole,%nsi %k+i2i+%s' !en !enin# in#k%+% k%+%n n ,el% ,el%k ks%si s%si -%n is+i is+i,% ,%h% h%++  psikolo#is -%p%+ menu,unk%n kele+ih%n 3isik' Menin#k%+k%n ,%s% n*%m%n %k%n meni menin# n#k% k%+k +k%n %n +ole +ole,%n ,%nsi si 3isik 3isik +e,h +e,h%%-%p %p #e(%l% *%n# -i,%s%k%n'

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6

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1

9 P#na!ala$'anaan P#na!ala$'anaan Fa"ma$-l-%, Fa"ma$-l-%, an N-n Fa"ma$-l-%, Fa"ma$-l-%, A P#na!ala$'anaan P#na!ala$'anaan Fa"ma$-l-%, A-% "%n*%k %,% pen%n#%n%n *%n# -%p%+ -il%kuk%n p%-% pen-e,i+% leukemi% -%n

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: T& T&*&an *&an P#m.#la*a"an P#m.#la*a"an

Se+el%h mempel%(%,i ini& -ih%,%pk%n m%h%sis/% -%p%+ mem"e,ik%n %suh%n kepe,%/%+%n  p%-% klien -en#%n Leukemi% -en#%n "en%, "en%, -%n +ep%+' 4



DAFTAR PUSTAKA

7loom G F%/e++& D')' 4664' Buku 4664'  Buku a&ar $istolog#' $istolog#' J%k%,+%$ E?C 7u,ke& J'M' 4614' '()R( 4614'  '()R( leukemia' leukemia' Mississ%u#%$ Jones G 7%,+le++ Le%,nin# Cui& D' 4611' Atlas 4611'  Atlas of $istolog#' $istolog#' !hil%-elphi%$ Lippino++ )illi%ms G )ilkins ?ol-smi+h& C' 4614' Leukemia 4614'  Leukemia'' Minne%polis$ USA To-%* ?,een& J'H' 466<' *isiologi 466<'  *isiologi ke"okteran. T%n#e,%n#$ T%n#e,%n#$ 7in%,up% Aks%,% H%n-%*%ni&)' G H%,i"o/o& A'S' 4668'  Buku a&ar asu$an kepera+atan kepera+atan pa"a klien "engan  gangguan sistem $ematologi. $ematologi. J%k%,+%$  J%k%,+%$ S%lem"% Me-ik% Meh+%& A' G Ho33",%n-& ' 4668'  At a glance $ematologi' $ematologi' J%k%,+%$ E,l%n##% Meshe,& A'L' 4611' istologi 4611'  istologi "asar ,unueira' ,unueira' J%k%,+%$ E?C Mu++%in& A' 466<' Asu$an 466<'  Asu$an kepera+atan klien "engan "engan gangguan Su-o*o& A') -kk' 466<' lmu 466<'  lmu pen#akit "alam' "alam' J%k%,+%$ In+e,n% !u"lishin# )on#& D'L -kk' 466<' Buku  Buku a&ar kepera+atan pe"iatrik ' J%k%,+%$ E?C

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