MAKALAH SISTEM PESYARAFAN 2
HIDROSEFALUS
Oleh: KELOMPOK 1
ADEK DIAN S.
(111420110048)
FADLILLAH
(111420110056)
HERI
(111420110060)
IMAM
(111420110061)
ISMAIL
(111420110062)
RIADOTUS SHILATIN N
(111420110079)
PROGRAM STUDI ILMU KEPERAWATAN STIKES NGUDIA HUSADA MADURA BANGKALAN 2012
i
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LEMBAR PERNYATAAN
Dengan ini kami menyatakan bahwa : Kami mempunyai salinan dari makalah ini yang bisa kami serahkan ulang jika makalah yang di kumpulkan hilang atau rusak.
Makalah ini adalah hasil karya kami sendiri (kelompok 1) dan bukan karya orang lain kecuali yang telah kami tuliskan dalam referensi, serta tidak ada seorangpun yang membuatkan makalah ini untuk kami.
Jika dikemudian hari terbukti adanya ketidakjujuran akademik, kami bersedia mendapatkan mendapatkan sanksi sesuai peraturan yang berlaku.
Bangkalan, Penulis,
Kelompok 1
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LEMBAR PENILAIAN MAKALAH DAN PRESENTASI KELOMPOK FORMAT PENIALAIAN MAKALAH (50 %) No
Aspek yang
Kriteria Penilaian
dinilai
1.
Nilai max
Pendahuluan
a. Menjelaskan
topik,
0-5
tujuan dan deskripsi singkat makalah b. Spesifik 2.
Isi
dan
Laporan lengkap
0-20
kesimpulan 3.
Daftar pustaka
a. Menggunakan aturan penulisan
daftar
pustaka yang baik dan benar b. Jumlah
minimal
referensi: buku (3), internet (5) dan jurnal (1) 4.
Penulisan
a. Jumlah halaman min.
makalah
10 (bab 1-penutup) b. Penulisan
bahasa
Indonesia yang baik dan benar termasuk tanda baca c. Logo (5x5 cm) d. Penggunaan
Theme
font times new roman font 12 spasi 1,5 e. Kertas A4 minimal 70
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referensi g. Kelengkapan
form
penilaian (wajib ada) 5.
Proses
a. Keaktifan konsultasi
Konsultasi
b. Kemampuan (responsive
0-10
diskusi dan
analisis) NILAI TOTAL (max 50)
KOMENTAR FASILITATOR
.......................................... ................................................................ ............................................ ............................................ .............................................. ........................ .......................................... ................................................................ ............................................ ............................................ .............................................. ........................ .......................................... ................................................................ ............................................ ............................................ .............................................. ........................ .......................................... ................................................................ ............................................ ............................................. .............................................. ....................... .......................................... ................................................................ ............................................ ............................................ .............................................. ........................ .......................................... ................................................................ ............................................ ............................................. ....................................... ................
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PRESENTASI KELOMPOK (maksimal 50) NO
ASPEK
Nilai
YANG DINILAI
1.
Kemampuan
0-10
mengemukakan intisari makalah 2.
Kemampuan
0-10
menggunakan media dan IT 3.
Kemampuan
0-30
berdiskusi (responsif, analisis) NILAI TOTAL Nb: Untuk nilai presentasi kelompok, jika tidak hadir maka otomatis 0. Jika
ingin menambah nilai, ada penugasan dari pengempu dengan nilai maksimal 20 (menghadap (menghadap wajib h+1) Soft Skill yang dinilai selama diskusi : teamwork, komunikasi Komentar fasilitator: .......................................... ................................................................ ............................................ ............................................ .............................................. ........................ .......................................... ................................................................ ............................................ ............................................. ............................................. ........................ .......................................... ................................................................ ............................................ ............................................ .............................................. ........................ .......................................... ................................................................ ............................................. ............................................. ............................................ ........................ .......................................... ................................................................ .......................................... ....................
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Penilaian mahasiswa lain/audien (maksimal 100) POINT
ASPEK
PENILAIAN
DINILAI
YANG
Selama proses
Aktif bertanya
diskusi
Aktif
(nilai
65-100)
memberikan
pendapat
Inovatif dan kreatif dalam memberikan pendapat
Kamampuan analitik
dalam
mangajukan pertanyaan
dan
memberikan solusi
Mahasiswa yang tidak hadir: 1. 2. 3. 4. 5. 6. Kriteria penilaian a. Mahasiswa yang bertanya/memberikan pendapat/menyimpulkan penilaian sama seperti di atas b. Mahasiswa hadir tapi tidak bertanya/memberikan pendapat/menyimpulkan, penilaian 60 c. Mahasiswa tidak hadir (nilai otomatis 0), kalau menginginkan nilai tambahan menghadap pengempu, pengempu, h+1, nilai nil ai maksimal 56
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DAFTAR ISI Halaman judul ............................................ ................................................................... ............................................. ............................. ....... i Lembar Pernyatan ......................................... ............................................................... ............................................ .......................... .... 2 Lembar Penilaian .................................................. ......................................................................... ......................................... .................. 3-6 Daftar Isi .......................................... ................................................................. ............................................. ........................................ .................. 7
Bab I
Pendahuluan .......................................... ................................................................ ............................................ ...................... 8-9
Bab II
Pembahasan........................................... ................................................................. ............................................ ...................... 11
Bab III
Asuhan keperawatan .......................................... ................................................................. ............................. ...... 32
Bab VI
Kesimpulan dan saran...................................... saran............................................................ ................................. ........... 52
Daftar Pustaka ............................. .................................................... ............................................. ............................................ ...................... 55
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BAB 1 PENDAHULUAN
1.1 Latar belakang
Hydrocephalus
telah
dikenal
sajak
zaman
Hipocrates,
saat
itu
hydrocephalus dikenal sebagai penyebab penyakit ayan. Di saat ini dengan teknologi yang semakin berkembang maka mengakibatkan polusi didunia semakin meningkat pula yang pada akhirnya menjadi faktor penyebab suatu penyakit, yang mana kehamilan merupakan keadaan yang sangat rentan terhadap penyakit yang dapat mempengaruhi janinnya, salah satunya adalah Hydrocephalus. Saat ini secara umum insidennya dapat dilaporkan sebesar tiga kasus per seribu kehamilan hidup menderita hydrocephalus. Dan hydrocephalus merupakan penyakit yang sangat memerlukan pelayanan keperawatan yang khusus. Hydrocephalus itu sendiri adalah akumulasi cairan serebro spinal dalam ventrikel serebral, ruang subaracnoid, ruang subdural (Suriadi dan Yuliani, 2001). Hydrocephalus dapat terjadi pada semua umur tetapi paling banyak pada bayi yang ditandai dengan membesarnya kepala melebihi ukuran normal. Meskipun banyak ditemukan pada bayi dan anak, sebenarnya hydrosephalus juga biasa terjadi pada orang dewasa, hanya saja pada bayi gejala klinisnya tampak lebih jelas sehingga lebih lebih mudah dideteksi dan diagnosis. diagnosis. Hal ini dikarenakan pada bayi bayi ubun-ubunnya masih terbuka, sehingga adanya penumpukan cairan otak dapat dikompensasi dengan melebarnya tulang- tulang tengkorak. Sedang pada orang dewasa tulang tengkorak tidak mampu lagi melebar. Angka kejadian hidrosefalus kira-kira 30 % yang di temui sejak lahir, dan
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Mahasiswa
keperawatan
perlu
mempelajari
cara
mencegah
dan
menanggulangi masalah hidrosefalus dengan student center learning berupa pembuatan makalah dan diskusi antar teman di kelas.
1.2 Rumusan masalah 1.1.1
Bagaimana anatomi dan fisiologi kepala?
1.1.2
Apa pengertian dari hidrosefalus?
1.1.3
Apa etiologi dari hidrosefalus ?
1.1.4
Sebutkan klasifikasi dari hidrosefalus ?
1.1.5
Bagaimana patofisiologi dari hidrosefalus ?
1.1.6
Apa saja manifestasi klinis pasien yang mengalami hidrosefalus ?
1.1.7
Bagaimana evaluasi diagnostik pada pasien hidrosefalus ?
1.1.8
Bagaimana penatalaksanaan penatalaksanaan pada hidrosefalus ?
1.1.9
Bagaimana komplikasi yang timbul pada pasien hidrosefalus?
1.1.10 Bagaimana prognosis pada hidrosefalus? 1.1.11 Bagaimana pencegahan primer, sekunder dan tersier yang harus
dilakukan pada pasien hidrosefalus ? 1.1.12 Bagaimana asuhan keperawatan yang dilakukan pada pasien yang
mengalami hidrosefalus ?
1.3 Tujuan 1.3.1 Tujuan umum
Menjelaskan tentang apa itu hidrosefalus dan bagaimana asuhan keperawatan yang harus dilakukannya
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1.3.8
Menjelaskan manifestasi klinis pada pasien yang mengalami hidrosefalus
1.3.9
Menjelaskan evaluasi diagnostik pada hidrosefalus
1.3.10 Menjelaskan penatalaksanaan penatalaksanaan pada pasien hidrosefalus 1.3.11 Menjelaskan komplikasi yang timbul pada pasien hidrosefalus 1.3.12 Menjelaskan prognosis pada pasien hidrosefalus 1.3.13 Menjelaskan pencegahan primer, sekunder, dan tersier yang dilakukan pada pasien hidrosefalus 1.3.14 Menjelaskan asuhan keperawatan pada pasien hidrosefalus
1.4 Manfaat a. Mengetahui dan menjelaskan apa itu hidrosefalus, cara menanganinya dan
bagaimana asuhan keperawatannya.
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BAB 2 PEMBAHASAN
2.1 Anatomi Dan Fisiologi Kepala (Menurut Maulana, 2010)
A. Kulit Kepala Kulit kepala terdiri dari 5 lapisan yang disebut SCALP yaitu; skin atau kulit, connective tissue atau jaringan penyambung, penyambung, aponeurosis atau galea aponeurotika, loose conective tissue atau jaringan j aringan penunjang longgar dan pericranium. B. Tulang tengkorak Tulang tengkorak terdiri dari kubah (kalvaria)
dan
basis
kranii.
Tulang
tengkorak terdiri dari beberapa tulang yaitu frontal, parietal, temporal dan oksipital. Kalvaria
khususnya
diregio
temporal
adalah tipis, namun disini dilapisi oleh otot temporalis. Basis cranii berbentuk tidak rata sehingga dapat melukai bagian dasar otak saat bergerak akibat proses akselerasi dan deselerasi. Rongga tengkorak dasar dibagi atas 3 fosa yaitu : fosa anterior tempat lobus frontalis, fosa media tempat temporalis dan fosa posterior ruang bagi bagian bawah batang otak dan serebelum.
C. Meningen Selaput meningen menutupi seluruh permukaan otak dan terdiri dari 3 lapisan yaitu :
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menyebabkan perdarahan subdural. Sinus sagitalis superior mengalirkan darah vena ke sinus transversus dan sinus sigmoideus. Laserasi Laserasi dari sinus-sinus ini dapat mengakibatkan mengakibatkan perdarahan hebat. Arteri-arteri meningeal terletak antara dura mater dan permukaan dalam dari kranium (ruang epidural). Adanya fraktur dari tulang kepala dapat menyebabkan laserasi pada arteri-arteri ini dan menyebabkan perdarahan epidural. Yang paling sering mengalami cedera adalah arteri meningea media yang terletak pada fosa temporalis (fosa media).
2. Selaput Arakhnoid (tengah) Selaput arakhnoid merupakan lapisan yang tipis dan tembus pandang. Selaput arakhnoid terletak antara pia mater sebelah dalam dan dura mater sebelah luar yang meliputi otak. Selaput ini dipisahkan dari dura mater oleh ruang potensial, disebut spatium subdural dan dari pia mater oleh spatium subarakhnoid yang terisi oleh liquor serebrospinalis. Perdarahan sub arakhnoid umumnya disebabkan akibat cedera kepala. a)
Ruang subaraknoid memisahkan lapisan arakhnoid dari pia mater dan
mengandung cairan serebrospinalis, pembuluh darah, serta jaringan penghubung
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dewasa sekitar 14 kg. Otak terdiri dari beberapa bagian yaitu; Proensefalon (otak depan) terdiri dari serebrum dan diensefalon, mesensefalon (otak tengah) dan rhombensefalon (otak belakang) terdiri dari pons, medula oblongata dan serebellum. Fisura membagi otak menjadi beberapa lobus. Lobus frontal berkaitan dengan fungsi emosi, fungsi motorik dan pusat ekspresi bicara. Lobus parietal berhubungan dengan fungsi sensorik dan orientasi ruang. Lobus temporal mengatur fungsi memori tertentu. Lobus oksipital bertanggungjawab dalam proses penglihatan. Mesensefalon dan pons bagian atas berisi sistem aktivasi retikular yang berfungsi dalam kesadaran dan kewapadaan. Pada medula oblongata terdapat pusat kardiorespiratorik. Serebellum bertanggungjawab dalam fungsi koordinasi dan keseimbangan.
E. Cairan serebrospinalis Cairan
serebrospinal
(CSS)
dihasilkan oleh plexus khoroideus dengan kecepatan produksi sebanyak 20 ml/jam. Pleksus
koroid
adalah
jaring-jaring
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meliputi seluruh susunan saraf pusat (SSP). Hubungan antara system ventrikel dan ruang subaraknoid adalah melalui foramen Magendie di median dan foramen Luschka di sebelah lateral ventrikel IV. Aliran CSS yang normal ialah dari ventrikel lateralis melalui foramen Monroi ke ventrikel III, dari tempat ini melalui saluran yang sempit akuaduktus Sylvii ke ventrikel IV dan melalui foramen Luschka dan Magendie ke dalam ruang
subaraknoid
melalui
sisterna
magna.
Penutupan
sisterna
basalis
menyebabkan gangguan kecepatan resorpsi CSS oleh sistem kapiler (Ngastiyah, 1997). CSS yang berada di ruang subarakhnoid, merupakan cairan yang bersih dan tidak berwarna. Merupakan salah satu proteksi untuk melindungi jaringan otak dan medula spinalis terhadap trauma atau gangguan dari luar. Pada orang dewasa volume intrakranial kurang lebih 1700 ml, volume otak sekitar 1400 ml, volume cairan serebrospinal serebrospinal 52-162 ml (rata-rata 104 ml) dan darah sekitar 150 ml.
F. Tentorium Tentorium
serebeli
membagi
rongga
tengkorak menjadi ruang supratentorial (terdiri dari
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waktu. Keadaan normal dari TIK bergantung pada posisi pasien dan berkisar ± 15 mmHg. Ruang cranial yang kalau berisi jaringan otak (1400 gr), Darah (75 ml), cairan cerebrospiral (75 ml), terhadap 2 tekanan pada 3 komponen ini selalu berhubungan dengan keadaan keseimbangan Hipotesa Monro – Kellie menyatakan : Karena keterbatasan ruang ini untuk ekspansi di dalam tengkorak, adanya peningkatan salah 1 dari komponen ini menyebabkan perubahan pada volume darah cerebral tanpa adanya perubahan, TIK akan naik. Peningkatan TIK yang cukup tinggi, menyebabkan turunnya batang otak (Herniasi batang otak) yang berakibat kematian. I.
Ventrikel otak Sistem ventrikel terdiri dari 2 buah
ventrikel lateral, ventrikel III dan ventrikel IV. Ventrikel lateral terdapat di bagian dalam serebrum, masingmasing ventrikel terdiri dari 5 bagian yaitu kornu anterior, kornu posterior, kornu inferior, badan dan atrium. Ventrikel III adalah suatu rongga sempit di garis tengah yang berbentuk corong
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Pada saat cedera, segera terjadi massa seperti gumpalan darah dapat terus bertambah sementara TIK masih dalam keadaan normal. Saat pengaliran CSS dan darah intravaskuler mencapai titik dekompensasi maka TIK secara cepat akan meningkat. Sebuah konsep sederhana dapat menerangkan tentang dinamika TIK. Konsep utamanya adalah bahwa volume intrakranial harus selalu konstan , konstan , konsep ini dikenal dengan Doktrin Monro-Kellie. Otak memperoleh suplai darah yang besar yaitu sekitar 800ml/min atau 16% dari cardiac output, untuk menyuplai oksigen dan glukosa yang cukup. Aliran darah otak (ADO) normal ke dalam otak pada orang dewasa antara 50-55 ml per 100 gram jaringan otak per menit. Pada anak, ADO bisa lebih besar tergantung pada usainya. ADO dapat menurun 50% dalam 6-12 jam pertama sejak cedera pada keadaan cedera otak berat dan koma. ADO akan meningkat dalam 2-3 hari berikutnya, tetapi pada penderita yang tetap koma ADO tetap di bawah normal sampai beberapa hari atau minggu setelah cedera. Mempertahankan tekanan perfusi otak/TPO (MAP-TIK) pada level 60-70 mmHg sangat direkomendasikan untuk meningkatkan ADO.
2.2 Pengertian Hidrosefalus
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Hidrosefalus
merupakan
penumpukan
cairan
serebrospinalis
secara
berlebihan di dalam rongga ventrikulus otak, paling sering terjadi pada neonatus. Keadaan ini juga dapat ditemukan pada dewasa sebagai akibat cedera atau penyakit. Pasda bayi, hidrosefalus membuat kepala membesar dan pada bayi maupun dewasa, kompresi yang ditimbulkan dapat merusak jaringan otak (Mayer, 2003). Hidrocephalus adalah sebuah kondisi yang disebabkan oleh produksi yang tidak seimbang dan penyerapan dari cairan cerebrospinal (CSS) di dalam sistem Ventricular. Ketika produksi CSS lebih besar dari penyerapan, cairan cerebrospinal cerebrospinal mengakumulasi di dalam sistem Ventricular (nining,2008). Pelebaran ventrikuler ini akibat ketidakseimbangan antara produksi dan absorbsi cairan serebrospinal. Hidrosefalus selalu bersifat sekunder, sebagai
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dalam suatu sistem, yakni sistem internal dan sistem eksternal. Pada orang dewasa normal jumlah CSS 90-150 ml, anak umur 8-10 tahun 100-140 ml, bayi 40-60 ml, ml , neonatus 20-30 ml dan prematur kecil 10-20 ml. Cairan yang tertimbun dalam ventrikel 500-1500 ml (Darsono, ( Darsono, 2005). Aliran CSS normal ialah dari ventrikel lateralis melalui foramen monroe ke ventrikel III, dari tempat ini melalui saluran yang sempit akuaduktus Sylvii ke ventrikel IV dan melalui foramen Luschka dan Magendie ke dalam ruang subarakhnoid melalui sisterna magna. Penutupan sisterna basalis menyebabkan gangguan kecepatan kecepatan resorbsi CSS oleh sistem kapiler. (DeVito EE et al, 2007:32) Hidrosefalus terjadi bila terdapat penyumbatan aliran cairan serebrospinal (CSS) pada salah satu tempat antara tempat pembentukan CSS dalam sistem ventrikel dan tempat absorbsi dalam ruang subaraknoid. Akibat penyumbatan, terjadi
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yang dapat sedemikian besarnya sehingga merupakan suatu kista yang besar di daerah fosa pascaerior.
4. Kista araknoid Dapat terjadi kongenital tapi dapat juga timbul akibat trauma sekunder suatu hematoma.
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daerah lain. Pada meningitis serosa tuberkulosa, perlekatan meningen terutama terdapat di daerah basal sekitar sistem kiasmatika dan interpendunkularis, sedangkan sedangkan pada meningitis purunlenta lokasisasinya lebih tersebar. 3) Neoplasma (tumor) Hidrosefalus oleh obstruksi mekanik yang dapat terjadi di setiap tempat aliran CSS. Pengobatannya dalam hal ini di tujukan kepada penyebabnya dan apabila tumor tidak di angkat, maka dapat di lakukan tindakan paliatif dengan mengalihkan CSS melalui saluran buatan atau pirau. Pada anak, penyumbatan ventrikel IV atau akuaduktus Sylvii biasanya suatu glioma yang berasal dari serebelum, penyumbatan penyumbatan bagian depan ventrikel III disebabkan kraniofaringioma. 4) Perdarahan Perdarahan sebelum dan sesudah lahir dalam otak, dapat menyebabkan
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3. Proses terbentuknya Dikenal hidrosefalus akut dan hidrosefalus kronik. Hidrosefalus akut adalah hidrosefalus yang terjadi secara mendadak sebagai akibat obstruksi atau gangguan absorpsi CSS (berlangsung dalam beberapa hari). Disebut hidrosefalus kronik apabila perkembangan hidrosefalus terjadi setelah aliran CSS mengalami obstruksi beberapa minggu (bulan-tahun). Dan diantar waktu tersebut disebut hidrosefalus subakut. 4. Sirkulasi CSS, dikenal hidrosefalus komunikans dan hidrosefalus non komunikans. 5. Hidrosefalus interna menunjukkan adanya dilatasi ventrikel, hidrosefalus eksternal menunjukkan adanya pelebaran rongga subarakhnoid di atas permukaan korteks. Hidrosefalus obstruktif menjabarkan kasus yang mengalami obstruksi
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2. Didapat Bayi atau anak mengalaminya pada saat sudah besar, dengan penyebabnya adalah penyakit-penyakit tertentu misalnya trauma, TBC yang menyerang otak dimana pengobatannya tidak tuntas. Pada hidrosefalus di dapat pertumbuhan otak sudah sempurna, tetapi kemudian terganggu oleh sebab adanya peninggian tekanan intrakranial.Sehingga
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Biasanya diakibatkan obstruksi dalam sistem ventrikuler yang mencegah bersikulasinya CSS. Kondisi tersebut sering dijumpai pada orang lanjut usia yang berhubungan dengan malformasi congenital pada system saraf pusat atau diperoleh dari lesi (space occuping lesion) ataupun bekas luka. Pada klien dewasa dapat terjadi sebagai akibat dari obstruksi lesi pada sistem ventricular atau bentukan jaringan adhesi atau bekas luka didalam system di dalam system
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massa cranial. Jika Fontanela anterior tidak tertutup, maka fontanel ini tidak akan berkembang dan terasa tegang pada perabaan. Stenosis aquaduktus menyebabkan titik pelebaran pada ventrikel lateral dan tengah, pelebaran ini menyebabkan kepala berbentuk khas, yaitu dahi tampak menonjol secara dominan (dominan frontal blow). Sindrom dandy-Walker dandy-Walker terjadi jika karena karena adanya obstruksi pada foraminal di luar pada ventrikel IV. Ventrikel IV melebar dan fosa pascaerior
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3. Peningkatan tekanan sinus venosa venosa Sebagai konsekuesi dari 3 mekanisme di atas adalah peningakatan tekanan intrakranial sebagia upaya mempertahankan keseimbangan sekresi dan absorbsi. Mekanisme terjadinya dilatasi ventrikel masih belum dapat dipahami secara terperinci, namun hal ini bukannlah hal yang sederhana sebagaimana akumulasi akibat dari ketidakseimbangan antara produksi dan absorbsi. Mekanisme
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Konsekuensi klinis dari hipertensi vena ini tergantung dari kompliens tengkorak. Bila sutura kranial sudah menutup, dilatasi ventrikel akan diimbangi dengan peningkatan volume vaskuler, dalam hal ini peningkatan tekanan vena akan diterjemahkan dalam bentuk klinis dari pseudotumor serebri. Sebaliknya, bila tengkorak masih dapat menghadaptasi, kepala akan membesar dan volume cairan akan bertambah. Derajat peningkatan resistensi aliran cairan likour dan
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