ASUHAN KEPERAWATAN PADA AN. I DENGAN GEDS DI RUANG MERPATI RSU TUGUREJO
Oleh : SITI MUTRIKAH 003784
AKADEMI KEPERAWATAN NGUDI WALUYO UNGARAN 2005
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BAB I TINJAUAN TEORI
A. DEF DEFINIS INISII
Gastroenteritis adalah inmflamasi atau infeksi yang disebabkan oleh bakteri agen agen bakteri bakteri atau virus virus dengan dengan gejala gejala sindro sindrom m klinik klinik adalah adalah diare, diare, mual, mual, muntah dan demam. (Carpenito, 1999 : 141) Diare adalah keadaan frekuensi buang air besar lebih dari 4 kali pada bayi dan lebih dari 3 kali pada anak; konsistensi feces encer, dapat berwarna hijau atau dapat pula bercampur lendir dan darah atau lendir saja. (Ngastiyah, 1997 : 143)
B. ET ETIIOL OLOG OGII
Ada beberapa penyebab dari diare ; 1.
Faktor infeksi a. Infe Infeks ksii ente entern rnal al : infe infeks ksii salu salura ran n penc pencer erna naan an yang yang meru merupa paka kan n penyebab utama diare yaitu meliputi : -
Infeksi ba bakteri : Vibrio, Sa Salmonella.
-
Infe Infek ksi viru viruss : Entero tero viru irus, Nati Nativ viris irisis is,, Astro strovi viru russ
-
Infeksi pa parasit : cacing as ascaris, pr protozoa.
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b. b. Infe Infeks ksii par paren ente tera rall yaitu infeksi dibagian tubuh lain di luar saluran pencernaan seperti Otitis Otitis Media Media Akut Akut (OMA), (OMA),ten tensil silia ia fungit fungitis, is, keadaa keadaan n ini terutam terutamaa terdapat pada bayi dan anak berumur di bawah 2 tahun. 2.
Faktor malabsorbsi a.
Malabsorpsi
karbohidrat
:
di
sakarid sakaridaa (intol (intoleran eransi si laktos laktosa, a, maltos maltosaa dan sukros sukrosa); a); monosa monosakar karida ida (intoleran glukosa, fruktosa dan galaktosa). b.
Malabsorpsi lemak c.
3.
Malabsorpsi protein Faktor makanan
Makanan basi, beracun, atau alergi terhadap makanan. 4.
Faktor psikologis
Rasa Rasa takut takut dan cemas cemas meningka meningkatka tkan n rangsa rangsanga ngan n para para simpat simpatis is
yang yang
meningkatkan mobilitas usus.
Mekanisme dasar yang menyebabkan diare : 1. Gang Ganggu guan an osmo osmoti ticc Akib Akibat at terd terdap apat atn nya mak makann ann
atau atau zat zat
yang yang tida tidak k
dap dapat dise disera rap, p,
menyeb menyebabk abkan an tekana tekanan n osmit osmitik ik dalam dalam rongga rongga usus usus mening meninggi gi sehing sehingga ga terjadi pergeseran air dan elektrolit ke dalam rongga usus dan selanjutnya timbul diare.
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2. Gang Ganggu guan an sekr sekres esii Akibat Akibat rangsangan rangsangan tertentu (misalnya makanan pedas atau beracun) pada dinding dinding usus akan terjadi terjadi peningkatan peningkatan sekresi sekresi air dan elektrolit elektrolit ke dalam rongga usus dan selanjutnya menyebabkan diare 3. Gang Ganggu guan an mob mobil ilit itas as usus usus.. Hiperp Hiperperis eristalt taltik ik menyeb menyebabk abkan an berkur berkurang angny nyaa kesemp kesempatan atan usus usus untuk untuk menyerap menyerap cairan dalam makanan makanan sehingga sehingga timbul diare, sedangkan sedangkan jika peristaltic peristaltic menurun menurun akan berakibat bakteri bakteri timbul timbul berlebihan berlebihan sehingga sehingga menimbulkan diare. (Nelson, Waldo E. 2002)
C. PATO PATOFI FISI SIOL OLOG OGII
Viru Viruss masu masuk k keda kedala lam m trak traktu tuss di gest gestiv ivus us bers bersam amaa maka makana nan n dan dan minuman, kemudian berkembang biak didalam usus setelah itu virus masuk ke dalam epitel usus halus dan merusakkan bagian apikal villi usus halus, sel epitel usus halus bagian epitel akan dig anti oleh sel dari bagian kripto yang belum matang, berbentuk kuboid atau gepeng, akibatnya sel-sel epitel ini tidak dapat berfungsi untuk mnyerap makanan dan air sebagai akibat lebih lanjut akan terjadi terjadi diare osmotic. osmotic. Villi usus kemudian kemudian akan memendek memendek sehingga sehingga kemapuannya untuk menyerap dan mencerna amakanan pun kurang pada saat inilh diare timbul.
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Bakteri masuk kedalam traktus di gevutus, kemudian berkembang bik didalamnya, bakteri ini lalu mengeluarkan toksin yang akan mengeluarkan toks toksin in yang yang akan akan meran merangs gsan ang g epit epitel el usus usus sehi sehing ngga ga terja terjadi di peni pening ngka kata tan n aktivitas enzim adenilsiklase atau quanilsiklase, sehingga akibat peningkatan aktivitas enzim-enzim ini akan terjadi peningkatan. CAMP CAMP (cycli (cyclicc adenos adenosine ine monoph monophosp ospate) ate) atau atau CGMP CGMP (cycli (cyclicc guanos guanosine ine monophospate) yang mampu merangsang sekresi klorida, natrium dan air dari dalam sel kelumen usus serta menghambat absorbsi natrium, klorida di lubang usus ke dalam sel, hal ini lalu menyebabkan hiperperistaltik usus sehingga cairan cairan di alirka alirkan n ke lumen lumen usus usus besar, besar, jika jika kemapu kemapuan an penyer penyerapa apan n kolon kolon berkurang atau skeresi cairan melebihi kapasitas, penyerapan kolon (4.400 ml) maka akan terjadi diare. Makanan yang terlalu pedas, asam, terlalu banyak serat dan lemak dapat merangsang peristaltic usus dan mengakibatkan diare. Maka Makana nan n yang yang tida tidak k dapa dapatt dise disera rap p atau atau dice dicern rna, a, misa misaln lnya ya lakt laktos osaa di fermentasikan oleh bakteri anaerob di dalam kolon menjadi molekul yang lebih kecil yaitu H2, CO2, H2O dan menyababkan tekanan osmotic didalam lumen usus yang yang hiper osmotar ini kemudian kemudian akan menyerap menyerap air dalam intra seluler diikuti peningkatan peristaltic usus sehingga terjadi diare. Proses diare akut di simpulkan sebagai berikut : 1.
jasa jasad d reni renik k masu masuk k ke dala dalam m usus usus halus halus etela etelah h berh berhas asil il mela melalu luii asam asam lambung
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3.
akib akibat at toks toksin in ters terseb ebut ut terj terjad adii hi[e hi[erte rtens nsii yang yang sela selanj njut utny nyaa meni menimb mbul ulka kan n diare untuk diare kronis lebih komplek dan factor yang menimbulkan ialah infeksi, bakteri, parasit, malabsorbsi, malnutrisi dan lain-lain.
D. MANIFE MANIFESTA STASI SI KLINIS KLINIS
Mula-mula anak cengeng, gelisah, suhu tubuh meningkat, nafsu makan berkurang atau tidak ada, lalu timbul diare, tinja cair mungkin di sertai lendir atau darh, warna tinja makin lama kehijauan. Karena bercampur dengan getah empedu anus dan daerah sekitarnya biasanya timbul kemerahan sambil lecet karena sering defekasi dan tinja semakin asam karena banyak asam lekatat uang berasal dari laktosa yang tidak diabsorbsi oleh usus selama diare, gejala mintah mintah bias bias timbul timbul sebelu sebelum m atau sesuda sesudah h diare, diare, dapat dapat diseba disebabka bkan n karena karena lambung yang turut meradang atau terjadi ketidakseimbangan asam-basa dan elektro elektrolit, lit, bila bila pasien pasien banyak banyak kehila kehilanga ngan n cairan cairan dan elektro elektrolit lit maka maka akan akan mengalami dehidrasi. Penentuan derajat dehidrasi : 1. Dehi Dehidr dras asii ring ringan an a. Keadaa Keadaan n umum umum:: haus, haus, sadar, sadar, gelisa gelisah h b. Nadai Nadai radian, radian, nafas nafas ubunubun-ub ubun un besar besar normal normal c. Elasti Elastiss kulit kulit pada pada pencub pencubita itan n segera segera kemba kembali. li. d. Mata Mata nor norma mall dan dan ada ada air air mat mataa e. Sela Selapu putt lend lendir, ir, lemb lembab ab
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g. BB men menu urun run 4-5 4-5 % 2. Dehi Dehidr dras asii seda sedang ng a. KU haus, haus, gelisa gelisah, h, letha lethargi rgi,, tetap tetap irritab irritable le b. b. Nadi Nadi radi radial alis is cepa cepatt dan lem lemah ah c. Pernaf Pernafasa asan n dalan dalan dan mungki mungkin n cepa cepatt d. Ubun Ubun-u -ubu bun n besa besarr dan cek cekun ung g e. Elasti Elastisit sitas as kulit kulit bila bila dicubi dicubitt lambat lambat kembal kembalii f. Mata Mata cekung cekung,, air mata mata kerin kering, g, selap selaput ut lendi lendirr kering kering g. BAK BAK berk berkur uran ang g dan dan war warna na tua tua h. BB meni mening ngka katt 6-9 6-9% % 3. Deh Dehidra idrasi si ber berat at a. KU : mengan mengantuk, tuk, lemas, lemas, ekstrei ekstreimtyas mtyas dingin, dingin, berkering berkeringat, at, sianotik, sianotik, mungkin koma b. Nadi Nadi radial radial cepat cepat dan kadang kadang tida tidak k teraba teraba c. Elastisitas Elastisitas kulit dalam cubitan cubitan kembali kembali sangat sangat lambat lambat (≥ 2 detik) d. Pern Pernafa afasa san n dalam dalam dan dan cepa cepatt e. Mata Mata sang sangat at ceku cekung ng
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E. PEMERI PEMERIKSA KSAAN AN LABORA LABORATOR TORIUM IUM
a. Medis -
terap terapii cairan cairan ses sesua uaii denga dengan n ting tingka katt dehid dehidras rasii
-
peng pengob obat atan an fotik fotik (ASI (ASI atau atau susu susu formul formulaa yang yang menga mengand ndun ung g renda rendah h laktosa dan asam lemak)
-
peng pengob obat atan an ant antii sekr sekres esii dan dan anti anti deh dehid idra rasi si
-
obat pengera eras fes feses
-
obat obat ant antii spa spasm smol oliti itik k dan dan anti anti pire pireti tik k
b. b. Kep Keperaw erawat atan an -
Kebe Kebers rsih ihan an pero perora rang ngan an,, cuci cuci tang tangan an sebe sebelu lum m maka makan n mema memaka kaii alas alas kaki saat bermain di tanah.
-
Mengan Menganjur jurkan kan agar agar tida tidak k member memberii maka makanan nan terbuk terbukaa
-
Hind Hindar arii mak makan anan an yang ang bas basii
-
Member Memberika ikan n pelatih pelatihan an pembu pembuatan atan laru larutan tan gula gula-ga -garam ram (CGG) (CGG) seba sebagai gai pengganti sebagai dehidrasi awal. (Mansjoer Arief, 2000)
F. FOKUS ITERVENSI
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-
monitor KU KU dan TTV
-
anju anjurk rkan an peni pening ngka kata tan n cai cairan ran pero peroral ral
-
moit moitor or inta intake ke dan dan out outp put
-
kaji kaji turg turgor or kuli kulitt dan dan memb membra rane ne muko mukosa sa
-
kolabo kolaboras rasii denga dengan n tim tim medi mediss dan dan pember pemberian ian terapi terapi obat obat.. (Whaley dan Wong, 1999)
b. b. Peru Peruba baha han n nutr nutris isii kuran kurang g dari dari kebu kebutu tuha han n tubu tubuh h berh berhub ubun unga gan n deng dengan an intervensi intake yang tidak adekuat. Tujuan : peningkatan asupan nutrisi untuk menyesuaikan BB dengan umurnya. Intervensi : -
Sete Setela lah h dehi dehidr dras asii anju anjurk rkan an teta tetap p minu minum m ASI ASI
-
Obse Observ rvas asii dan dan catat catat res respo pon n mak makan an pasi pasien en
-
Berita Beritahu hu ibu ibu untuk untuk member memberika ikan n diet diet bubur bubur dan dan makan makanan an tamba tambahan han
sesuai diet -
Hind Hindari ari maka makana nan n yan yang g mera merang ngsa sang ng munt muntah ah
-
Anjurk Anjurkan an keluar keluarga ga tentan tentang g pentin pentingny gnyaa nutris nutrisii bagi pend penderit eritaa diare. diare.
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-
Anjurk Anjurkan an pada pada ibu ibu untuk untuk sege segera ra membe membersi rsihka hkan n setiap setiap anak anak habi habiss bab
-
Anju Anjurk rkan an kepad kepadaa ibu untuk untuk menjag menjagaa tetap tetap keri kering ng daerah daerah pant pantat at dan mengganti pakaian kering.
-
Kola Kolabo bora rasi si med medis is untu untuk k pemb pember erian ian salp salp.. (Doenges, 2000)
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Pathway
Infeksi (bakteri,virus,parasit
Makanan beracun
Pergheseran cairan dan elektrolit ke rongga usus
Reaksi inflamasi
Kenaikan suhu tubuh
Malabsorbsi
Isi rongga usus meningkat
psikologis
Rangsangan parasimpatis meningkat
Motilitas usus
Hipermobilitas Usus Sekresi air dan elektrolit meningkat
diare
Tubuh kehilangan cairan dan elektrolit
Sering defakasi
Penurunan volume cairan ekstra sel dan intra sel
Kemerahan dan iritasi sekitar kulit anus
Output berlebihan absorbsi berkurang
Penurunan nutrisi
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BAB II TINJAUAN KASUS
A. PENG PENGKA KAJI JIAN AN
Pengkajian ini dilakukan pada tanggal 7 juni 2005 jam 10.00 WIB di ruang melati RSU Tugurejo semarang dengan allow anamnesa 1.
Identitas a. Iden Identi tita tass pas pasie ien n Nama
: An. I
Umur
: 7 bulan
Alamat
: Wonoharjo, Kembangaren Semarang
Pendidikan
:-
Tgl masuk
: 5 Agustus 2005
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2.
Keluhan utama :
Ibu pasien mengatakan BAB sudah 7 x dengan konsistensi cair 3.
Riwayat kesehatan a. Riwa Riwaya yatt kes keseh ehat atan an seka sekaran rang g Ibu pasien mengatakan anaknya BAB ± 3 hari dengan frekuensi 5 / hari di sertai lendir dan kejang di rumah pasien sudah di bawa ke bidan dan dibe diberi ri larut larutan an gula gula gara garam/ m/or oral alit it dan dan anti antibi biot otic ic tetap tetapii belu belum m ada ada perub perubaha ahan n kemudi kemudian an oleh oleh keluar keluargan ganya ya di bawa bawa ke RSU tugu rejo rejo semarang untuk mendapatkan perawatan dan pengobatan dan pada saat di kaji pasien tampak lemah, S = 38 0 C ibu pasien mengatakan sudah 7 x BAB cair. b. b. Riwa Riwaya yatt keseh kesehat atan an terd terdah ahul ulu u Ibu pasien menatakn bahwa pasien belum pernah mengalami penyakit
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B. PENGKAJIAN PENGKAJIAN POLA FUNGSIONAL FUNGSIONAL MENURUT MENURUT GORDON GORDON
1.
Pers ersepsi epsi keseh esehat atan an dan pola ola Man Manaj ajem emen en Kes Kesehat ehatan an
Keluarga belum mengerti tentang penyakit yang di derita pasien karena itu ibu sering sering bertan bertanya ya pada pada perawa perawat/d t/dokt okter er tentan tentang g perkem perkemban bangan gan dan kondis kondisii pasien pasien.. Keluar Keluarga ga hanya hanya menget mengetahu ahuii kalau kalau penyak penyakit it anakny anaknyaa tersebut hanya diare biasa. 2.
Pola nutrisi dan metabolisme.
Sebelum Sebelum sakit : pasien mau mau minum dan makan makan porsi sedang sedang habis habis dengan komposisi bubur. Selama Selama sakit sakit : pasien pasien hany hanyaa habis habis ¼ porsi porsi dengan dengan komp komposi osisi si bubur bubur 3.
Pola Eliminasi
Sebelum Sebelum sakit sakit : pasien BAB BAB 1-2 x/hari x/hari dan BAK 6-7x/hari 6-7x/hari cair, cair, BAK bau khas.
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6.
Pola Persepsi dan Kognitif
Pasien Pasien terlihat terlihat tenang tenang bila bila keluar keluargan ganya ya
berada berada di sisiny sisinyaa dan pasien pasien
menangis saat ditinggalkan ibunya. 7.
Pers ersepsi epsi Pola ola Kons Konsep epsi si diri diri dan konse onsep p diri diri
Peran pasien dalam keluarga adalah sebagai anak, pasien dapat melakukan aktivtas fisiknya secara optimal dan tidak mengalami cacat fisik. 8.
Pola Peran dan Hubungan
Hubungan dengan social selama di rumah sakit hanya dengan keluarga. 9.
Pola se seksualitas da dan re reproduksi
Pasien berjenis kelamin laki-laki unur 5 bulan, alat kelamin lengkap terab sputum tidak ada kelainan. 10.
Pola Ke Keyakinan da dan Ni Nilai
Sebelum sakit : pasien beragama Kristen dan keluarga berdoa untuk
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S
: 380 C
3.
Panjang badan : 40 cm
BB
: 6 ½ kg
4.
Bentuk kepala : Mesochepal
5. Mata
: Be B entuk si simetris, sk sklera ti t idak ik ikterik, ko konjungtiva ti tidak anemis
6. Hidung
: Si Simetris, be bersaih, ti tidak ad ada pe pembesaran po polip, ti tidak ad a da penumpukan secret, tidak pakai alat Bantu pernafasan
7.
Mulut
: Mukosa bibir kering, tidak ada stomatis.
8.
Telinga
: Be Bentuk si simetris, ti tidak ad ada pe penumpukkan se serumen,
tidak pakai alat Bantu pendengaran. 9.
Dada
Paru-paru
I
: Simetris tidak tarikan intercosta
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A
: Per Peris ista talt ltik ik usus usus 30 x/me x/meni nitt
Pe : Tympani Pa : Tid Tidak ak tera terasa sa masa masa kolo kolon n 11. 11. Gene Geneta tali liaa
: bers bersih ih,, lemb lembab ab,, tida tidak k terp terpas asan ang g kate katete ter. r.
12. Anus
: lembab, kemerahan tidak ada hemoroid, tidak ada lesi.
13.
Ekstremitas
Supe Superi rior or
: terp terpas asan ang g in infuse fuse RC 20 20 tts tts/m /mn nt pad padaa tan tanga gan n kan kanan an..
Inferio rior
: dapat bergerak bebas, as, tidak ada ada udem/lesi.
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- T cacing
:-
- eritrosit
:3–5
- leukosit
:4–7
- sisa makanan: 2.
Terapi
Infuse KAEN 3B 20 tts/mnt (mikro) Moraxime 2 x 1 gr Inamid Inamid 3 x 1 tab
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ANALISA DATA
Nama klien
: An. I
Umur
No
1.
No. register : 088874
: 7 hari
Dx. medis
Hari/tgl/jam
Senin,
Kemungkina
Masalah
n penyebab Out put yang
keperawatan Kura Kuran ng volu olume
berlebihan
cairan tubuh
Data fokus
DS : Ibu
8-8-2005 Jam 10.00 WIB
: GEDS
pasien
mengatakan
pasien BAB 7 x /hari DO :
pasi pasien en tamp tampak ak lema lemah h
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08-8-2005 jam 10.00 WIB
kalau
ana anaknya
serin ring BAB
BAB DO : pada pada daer daerah ah sek sekit itar ar anu anuss terlihat kemerahan dan lembab
integritas kulit
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Umur
No
1.
: 7 bulan
Diagnosa keperawatan
Gangguan
keseimbangan
c ai r a n
dan
kuran urang g
dari ari
outp output ut
yang yang
DS : ibu ibu pasi pasien en meng mengat ataka akan n
kebu ebutuh tuhan DO : - pasien tampak lemah
berl berleb ebih ihan an
: GEDS
Tanggal
Tanggal
Data fokus
elektrolit BAB 7 x /hari
tubuh berhubungan dengan
Dx. medis
- mata cekung mukosa bibir kering
Ttd ditemukan 8-8- 2005
teratasi
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berhubungan
dengansering BAB dan gelisah
seringnya BAB
DO : - pada daerah anus terlihat lembab daerah anus anus juga terlihat
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Umur
: 7 bulan
Dx. medis
: GEDS
No Hari/tgl/jam
Data fokus DX
intervensi
TTD
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09/08/2005 selasa
III
-
suhu pasien 360 C
-
mukosa bibir lembab
- kolabo aboras rasi
dalam
pemberi erian
antiseptic - anju anjurk rkan an kepad epadaa pasie asien n untu ntuk membersihkan
daerah
anus
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Rabu
Dx I
-
Monitor vital sign
- Jam Jam 10. 10.00 00 WI WIB B
10-08-05
N : 100 x/mnt
- S : 380 C
Jam10.00 WIB
S : 380 C
- N: 100 100 x/m x/mnt nt
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keluarga pasien untuk mengganti
melakukan anjuran
baju baju pasien pasien dengan dengan yang yang lebih lebih
perawat
tipis.
- Pasien Pasien mau mau di beri beri bedak bedak Memberikan
pada daerah anus yang
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