LAPORAN PENDAHULUAN ASUHAN KEPERAWATAN PADA PASIEN DENGAN GANGGUAN ELIMINASI URINE
OLEH: NI PUTU NARISKA RAHAY RAHAYUNI (1102105030)
PROGRAM STUDI ILMU KEPERAWATAN FAKULTAS KEDOKTERAN UNIVERSITAS UDAYANA 2012
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Trauma tulang belakang
Operasi pada abdomen bawah
Luka pada medulla spinalis (S2-S3)
Terdapat efek anestesi & analgesik narkotik
kerusaan saraf simpatis dan parasimpatis
mpuls sensorik dan motorik terganggu
"dan#a bekuan darah$ batu
'% karsinoma prostat striktur uretra trauma uretra
Obstruksi saluran kemih
Ter*adi pen#empitan saluran kemih
%engeluaran urine terhambat penimbunan urine di dalam esika urinaria
Kemampuan otot detrusor dan spingter untuk merespon keinginan berkemih Kesulitan untuk mengontrol urinasi
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6'"$ *!$/"''" /"&/ e"$//% +'/'" /%!"e ,e% 4' ,'*' !e" 6'"$ #&'&/# +e-*!"'!"6' &!*' #&'!. *. Pe"e$'+'" !"e#! K!e" 6'"$ *!'&e&e%!#'#! *','& e"$''! !"e#! e'/! e%'$'! '%'. Me,e%&'+'"'" *%'!"'#e /%!"e &e%&/&/, e%/,''" &!"*''" 6'"$ ,e"&!"$ /"&/ e"$-&%- !"e#!. S6#&e 6'"$ %/#' *','& e"6e''" '#/"6' -%$'"!#. D'e%'+ 6'"$ e!!! %e#!- !"! '*''+ *'e%'+ !"#e%#! '&e&e% '"&/"$ *%'!"'#e ', *'" #'/"$'" '"&'%' #e'"$ *'" '"&/"$. I%!$'#! *'" !"#&!'#! '&e&e% *!,e%/'" /"&/ e,e%&'+'"'" e,'&e"'" /%!"e e"e&', '*'"$'*'"$ ,e%/ /"&/ e"$!%!$'#! '&'/ e!'# '&e&e%. e. Me"$/'&'" -&-& *'#'% ,'"$$/ L'&!+'" *'#'% ,'"$$/ e"!"$'&'" e/'&'" -&-& *'#'% ,'"$$/ 6'"$ &e%*!%! *'%! -"&%'#! e-,- -&-& 6'"$ e%/'"$ (8/%e 1BB2) . 8'**e% %e&%'!"!"$ T/4/'" '**e% %e&%'!"!"$ !''+ /"&/ e"$e'!'" ,-' "-%' ,e%e!+'" *e"$'" e"$+''& '&'/ e"#&!/'#! ,e"$e/'%'" '!% e!+ (AH?PR 1BB2)
8. KONSEP DASAR ASUHAN KEPERAWATAN 1. Pe"$'4!'" (D'&' S/4e&! *'" O4e&!) 1) I*e"&!&'# P'#!e" N'' : U/% : A''& : Pee%4''" : N-. Re$ : T$. MRS : T$. Pe"$'4!'" : D Me*!# : 2) I*e"&!&'# Pe"'"$$/"$ C'' N'' : U/% : Pe"*!*!'" : Pee%4''" : H/. *$" ,'#!e" : 3) R!'6'& Ke#e+'&'" Ke/+'" /&'' : R!'6'& ,e"6'!& #e'%'"$ : R!'6'& e+'!'" *'" e'+!%'":
R!'6'& e#e+'&'" e/'%$':
;) Pe"$'4!'" F/"$#!-"' P-' G-%*-" '. P-' ,e%#e,#! *'" ,ee!+'%''" e#e+'&'" . P-' "/&%!#! *'" e&'-! . P-' '!%'" *'" e&'-! *. P-' !#&!%'+'& *'" &!*/% e. P-' '&!7!&'# *'" '&!+'" . P-' e!!"'#! $. P-' ,e%#e,#! *'" -$"!&! +. P-' %e,%-*/#! *'" #e#/' !. P-' ,e%#e,#! *'" -"#e, *!%! 4. P-' e'"!#e -,!"$ . P-' "!'! *'" e,e%'6''" 5) Pe"$'4!'" F!#! Ke'*''" // ,'#!e" Ke#'*'%'" Pee%!#''" TTV =) Pee%!#''" Pe"/"4'"$ Pee%!#''" L'-%'&-%!/ Pee%!#''" %'*!--$! A"'!#' *'&': '. D'&' #/4e&! : K!e" e"$'&''" #/!& /"&/ e%e!+ K!e" e%'#''" "6e%! e&!' #e*'"$ e%e!+ K!e" e%'#''" ,e%/&"6' e/"$ (*!#&e"#! '"*/"$ e!+) K!e" e"$'&''" &!*' *','& e%'#''" e!"$!"'" e%e!+ K!e" e"$'&''" &!*' *','& e"$+''& e%e!+ #e'%' 7-/"&e% . D'&' -4e&! : '. I"#,e#! M/-#' //& e%!"$ Te%!+'& '*'"6' ,ee"$''" ,'*' '*-e" '$!'" ''+. . P','#! P','#! $!"4' #e'' /"&/ e"$e&'+/! '*'"6' '#''+ #e,e%&! &/-%. P','#! '*-e" '$!'" ''+ '"*/"$ e!+ *'' e'*''" "-%' .
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2. D!'$"-#' Ke,e%''&'" Y'"$ M/"$!" M/"/ I"-"&!"e"#!' /%!"e Re&e"#! /%!"e
D!'$"-#' I"-"&!"e"#!' /%!"e %ee e%+//"$'" *e"$'" $'"$$/'" "e/%--$!# *!&'"*'! *e"$'"
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NOC Label: Urinary Continence
#e"#'#! ,e"/+
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1. Me"$e&'+/! e!"$!"'" e%e!+ (5) 2. Pe"$-#-"$'" '"*/"$ e!+ (5) 3. 8e%e!+ 150 #e&!', '! e%e!+ (;)
I"&e%7e"#! NIC Label: Urinary Incontinence Care
1. Ce'#'" ,e"6e' *'%! '#''+ *'" %'#!-"' *'%! &!"*''" 6'"$ *!'/'" 2. M-"!&-% e!!"'#! /%!"e e!,/&! %e/e"#! -"#!#&e"#! '/ 7-/e *'" '%"' 3. Me'"&/ /"&/ e"!"$'&'"9 e,e%&'+'"'" e!"$!"'" e%e!+ ;. I"#&%/#!'" ,'#!e"9e/'%$'"6' /"&/ e"'&'& e/'%'" /%!"e *'" ,-' e!!"'#! NIC Label: Urinary Catheterization
1. Ce'#'" ,%-#e*/% *'" %'#!-"' *'%! ,e'#'"$'" '&e&e%
Re&e"#! /%!"e e%+//"$'" *e"$'" #/'&'"
Se&e'+ *!e%!'" '#/+'" e,e%''&'" #e'' ..2; 4' *!+'%','" %e&e"#! /%!"e ,'*' !e" *','& e%/%'"$9&e%'&'#!. NOC Label: Urinary Elimination *e"$'" %!&e%!' +'#! :
2. M-"!&-% !"&'e *'" -/&,/& '!%'" (4/'+ '%"' %e/e"#!) NIC Label: Urinary Elimination Management 1. M-"!&-% e!!"'#! /%!"e e!,/&! %e/e"#! -"#!#&e"#! '/ 7-/e *'" '%"' 2. I*e"&!!'#! '&-% 6'"$ e%,e"$'%/+ &e%+'*', !"-&!"e"#!' 3. A"4/%'" ,'#!e"
R'#!-"' NIC Label: Urinary Incontinence Care 1. A$'% !e" e"$e&'+/! e"$e"'! -"*!#! *'" &/4/'" *'%! &!"*''" 6'"$ *!'/'" 2. U"&/ e"$e&'+/! '%'&e%!#&! *'%! +'/'%'" /%!"e 3. U"&/ e'&!+ *'" e!'#''" ,'#!e" e"$e&'+/! e!"$!"'" e%e!+"6' ;. Se'$'! ,e%'"*!"$'" #e+!"$$' *','& &e%!+'& ,e%/'+'" 6'"$ &e%4'*! ,'*' ,'#!e" NIC Label: Urinary Catheterization 1. A$'% !e" e"$e&'+/! e$/"''" *'" &/4/'" *'%! ,e'#'"$'" '&e&e% 2. U"&/ e"$e&'+/! ',''+ &e%4'*! e&!*'#e!'"$'" *'" ,e%/'+'" ,'*' e/'%'" /%!"e
E7'/'#! S : !e" e"$'&''" #/*'+ !#' e"$-"&%- e"$e&'+/! '$'!'"' ,-' e!!"'#! /%!"e"6' O : -/&,/& *'" !"&'e '!%'" #/*'+ "-%' *'" #e!'"$ (19$ 8894') %e/e"#! e%e!+ 6'"$ #e%!"$ ,'*' !e" /'! e%/%'"$ A : U%!"'%6 I"-"&!"e"e ?'%e &e%','! #e'$!'" P : !"&e%7e"#! U%!"'%6 I"-"&!"e"e ?'%e *!'"4/&'"
NIC Label: Urinary S : !e" e"$'&''" Elimination ,e%/&"6' #/*'+ &!*' Management "6e%! 1. U"&/ e"$e&'+/! O : !"&'e *'" -/&,/& '*' '&'/ &!*'"6' '!%'" #/*'+ "-%' e&!*'"-%''" *'%! *'" #e!'"$ e%e!+ !e" (19$ 8894') 2. U"&/ e"$e&'+/! A: U%!"'%6 +'+' 6'"$ E!!"'&!-" e"6e''" M'"'$ee"& !"-"&!"e"#!' &e%','! #e'$!'" 3. A$'% ,'#!e" *','&
1. P-' e!!"'#! /%!"e /"&/ #e$e%' e"$e&'+/! *'" !e" (5) e%e#,-" *-%-"$'" /'! e!'#''" 2. Pe"$-#-"$'" e%e!+ /"&/ e"$e&'+/! '"*/"$ e!+ (5) ,-' e%e!+"6' 3. Re&e"#! /%!"e (5) ;. A$'% e"$e&'+/! ;. N6e%! #''& e%e!+ ;. ?'&'& '&/ &e%'+!% !"&e%7' ,e%!%''" (5) e%e!+ e%e!+ NOC Label: Symptom #e'"4/&"6' NIC Label: Urinary NIC Label: Urinary Severity Catheterization 1. e&!*'"6''"'" (5) Catheterization 1. A$'% ,'#!e" 2. '"#!e&'# (5) 1. Ce'#'" ,%-#e*/% e"$e&'+/! &/4/'" 3. e$e!#'+'" (5) *'%! &!"*''" *'" *'" %'#!-"' *'%! *','& e"$/%'"$! ,e'#'"$'" '&e&e% ee'#'""6' 2. Te&', e"$$/"''" 2. A$'% &e%+!"*'% *'%! ,','%'" !%-' &e"! '#e,&! 6'"$ *','& 3. M-"!&-% !"&'e *'" e"6e''" -/&,/& '!%'" !"e#! 3. U"&/ e"$e&'+/! (4/'+ '%"' ',''+ &e%4'*! %e/e"#!) e&!*'#e!'"$'" *'" ,e%/'+'" ,'*' e/'%'" /%!"e
P: U%!"'%6 E!!"'&!-" M'"'$ee"& *!'"4/&'"
DAFTAR PUSTAKA NANDA I"&e%"'&!-"'. 2011. Diagnosis Keperawatan : Definisi dan Klasifikasi 2012-2014. C''%&' : EG?. D-+&e%'" C-'""e M. 8/e+e G-%!' N. 200;. Nursing Interventions Classification : Fourt !dition. U"!&e* S&'&e# - Ae%!' : M-#6. M--%+e'* S/e e& '. 200. Nursing "utco#es Classification : Fourt !dition. U"!&e* S&'&e# - Ae%!' : M-#6
P%!e S67!' A W!#-" L-%%'!"e M. 200=. $atofisiologi Konsep Klinis $roses-$roses $en%akit edisi & 'olu#e 2( C''%&': Pe"e%!& 8// Ke*-&e%'" EG? 8%--e% ?+%!#. 200B. !nsiklopedia Keperawatan( C''%&': EG? I##e'+e% K/%& C. e& '. 1BBB. )arrison $rinsip-$rinsip Il#u $en%akit Dala#. C''%&': EG? P-&&e% Pe%%6. 200=. *uku +,ar Funda#ental Keperawatan( C''%&': EG?
