BAB III ASUHAN KEPERAWATAN FASE PREOPERATIF A. PENG PENGKA KAJI JIAN AN 1. Peng Pengum umpu pula lann Dat Dataa a. Iden Ident tta ta!! pa! pa!en en Nama Umu# Jen! Kelamn Agama Su(u Pendd(an Alamat Pe(e#+aan Tanggal *a!u( Tanggal Peng(a+an Dagn0!a *ed!
" " " " " " " " " " "
Tn. S $% Ta&un 'a() la( I!lam *adu#a S*P Te(am Tda( ,e(e#+a -$)%$)1 -/)%$)1 Reten! U#ne BPH P#0 Open P#0!tate(t0m2
,. Identta! penanggung +a3a, Nama " N2. S Jen! Kelamn " Pe#empuan Hu,ungan " Ana( Pa!en
-. R3a R3a22at Pen Pen22a(t a(t a. Ala! Ala!an an ma!u ma!u(( #um #uma& a& !a( !a(tt Pa! Pa!en en me#u me#upa pa(a (ann pa! pa!en en ulan ulanga gann 2ang ang pe#n pe#na& a& meme meme# #(! (!a( a(an an (e!e (e!e&a &ata tann nn2a 2a d p0l p0l ,eda ,eda&& RSUD RSUD D# Ru, Ru,n n *emp *empa3 a3a& a& Pe#n Pe#na& a& mela(u(an anamne!! !ng(at pada tanggal -%)4)1 dengan (elu&an tda( ,!a Ba( !elama 4 &a#. Saat n pa!en mengelu&(an (elu&an 2ang !ama namun d!e#ta n2e# dan te#(adang Ba( ,e#da#a&. ,. Kelu&an utama Pa!en mengata(an n2e# pada ,agan pe#utn2a. P " N2e# N2e# (et (et(a (a ,e# ,e#ge ge#a #a(( dan dan dt dte( e(an an ,ag ,aga ann !2mp !2mp! !! ! 5 " Se Sepe#t d dtu!u( tu tu!u( R " Pada ,agan !2mp!! S " 6)4 T " Hlang tm,ul 25
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7. Kelu Kelu&a &ann Saa Saatt d( d(a+ a+ ) Pa!en Pa!en mengat mengata(an a(an n2e# n2e# pada pada ,aga ,agann !2m !2mp! p!!n2 !n2aa ) Pa!en Pa!en meng mengata ata(an (an !ul !ultt untu( untu( Ba( Ba( !uda& !uda& le, le,&& da# da# 1 ,ulan ,ulan 2ang 2ang lalu lalu ) Pa!en Pa!en meng mengata ata(an (an !e# !e#ng ng me#a! me#a!aa tda( tda( pua! pua! !etela& !etela& (en7n (en7ng g ) Pa! Pa!en en tampa tampa(( 7ema! 7ema! (a#en (a#enaa a(an a(an meng& meng&ad adap ap p#0! p#0!e! e! pem,e pem,eda da&an &an p#0!tat d. R3a2 R3a2at at Pen2 Pen2a( a(t t te#d te#da& a&ulu ulu Pa!en meml( #3a2at pen2a(t p#0!tat !emen+a( ,e,e#apa,ulan 2ang lalu dan !uda& - (al d ,a3a (e #uma& !a(t pa!en +uga mempun2a #3a2at pen2a(t D* t2pe II dan +uga Hpe#ten!. e. R3a2 R3a2at at (e! (e!e& e&ata atann (elu (elua# a#ga ga Tda( ada #3a2at (elua#ga 2ang meml( pen2a(t (#0n! 2ang !ama !epe#t pem,e!a#an p#0!tat D* t2pe II dan +uga Hpe#ten!.
8. GENOGRA*
Kete#angan " : Laki- laki meninggal : Perempuan
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"
" la()la( &dup " p#empuan &dup " pa!en
Data B0l0g!. a. P0la Nu Nut#! S*RS *RS
" Pa!en ma(an 8 (a !e&a# dengan menu ,e#9a#a! !atu p0#! &a,! " Pa!en tda( na:!u ma(anpa!en &an2a ma(an 1 (al !e&a# dan p0#! ma(an #uma& !a(t tda( &a,!.
,. P0la *num S*RS *RS 7. P0la 0la Elm Elmn na! a! S*RS *RS
" Pa!en mnum 4)$ gela! !e&a# ;1)-< lte# pe# &a# " Pa!en mnun - gela! !e&a# ;; -%)%%< 77 pe# &a# " pa!en !ult (en7ng =Ba( le,& da# 1 ,ulan " Ba( mengguna(an (atete# u#ne 90lume u#ne 1%%)%% 77 = &a# 3a#na u#ne tampa( (eme#a&an.
d. P0la P0la !t !t#a& #a&at at Tdu# du# S*RS " Pa!en tdu# )4 +am !e&a# *RS " Pa!en tda( ,!a tdu# !ama !e(al d(a#ena(an e. P0la H2g H2gene ene *and
n2e# !e#ng mun7ul
28
S*RS
" Pa!en mand !end# 8> !e&a# !e7a#a mand#
*RS
" Pa!en #utn d ,e#!&(an 0le& (elua#gan2a !e,an2a( -> !e&a# dengan 3a!lap a# &angat (eadaan !etela& mand 7u(up ,e#!&
?u7 Rm,ut S*RS *RS
" Pa Pa!en men7u7 #am,utn2a !aat mand " Pa!en &an2a mem,a!a& #am,utn2a !e!e(al dengan ,antuan (elua#ga
G0!0( gg S*RS *RS
" Pa!en g0!0( gg - (al !e&a# " Pa!en mengg0!0( gg 1 (al dengan ,antuan (elua#gan2a
6. P0la P0la a(t a(t99ta! ta! A(t9ta! *and Be#pa(aan Elmna! *0,l!a! d tempat tdu# Pnda& *a(an dan mnum
%
1
Be#at Badan
TD N RR S
8
√ √
@ @ @ @
Kete#angan " % " mand# 1 " D,antu !e,agan - " Pe#lu ,antuan 0#ang lan 8 " Pe#lu ,antuan 0#ng lan dan alat 6 " te#gantung 0#ang lan dan mad#. . Pem Peme#( e#(!a !aan an F! F!( ( a. Keadaan Umum Ke!ada#an TT
-
" 'ema& " ?0mp0! *ent! " 16%=% mmHg " /4 (al=ment " -/ (al=ment " A:e,#!
6
29
S*RS *RS Tngg Tngg Badan
" 4% (g ± pada 8 ,ulan 2ang lalu " (g " 14 7m BB
59
I *T
" (T B2) C ( 1,652) C -%%6
Kete#angan
" I*T N0#mal C 1/)-6 (g=
m
2
; I*T pa!en
dalam (eadaan n0#mal< ,. Kepala In!pe(!
" Bentu( (epala !met#!tda( ada lu(a tda( ada &d#07epalu!#am,ut tp! n2a#! ,0ta(,entu(
Palpa! 7. *ata In!pe(! Palpa! d. Hdung In!pe(! Palpa! e. Telnga In!pe(! Palpa! :. *ulut In!pe(! Palpa! g. le&e# In!pe(! Palpa! &. T&0#a> In!pe(!
l0n+0ng " Tda( ada n2e# te(an dan +uga ,en+0lan " (0 (0n+ungt9a me me#a& ma mata ! !met#! !7 !7le#a ,e ,e#3a#na (e#u&. " Tda( ada n2e# te(an dan pem,eng(a(an " Bentu( !met#! tda( ada !e(#et dan p0lp " Tda( ada n2e# te(an,en+0landan ,eng(a( " Be Bentu( ! !met#! ttda( ada (e (elanan !e !ed(t te#dapat !e#umendan tda( ada le! " Tda( ada ,en+0lan dan n2e# te(an " Gg tampa( (unng,,# tampa( (e#ng lda& !ed(t (0t0# mu(0!a mulut mulut lem,a, " Ot0t #a&ang (uat " tda( ada pem,e!a#an (elen+a# 9ena +ungula#! tampa( " a#te# (a#0t! te#a,a (uat tda(ada n2e# te(an " Dada !met#! tda( ada le!#e!p#a! 8% >=m tda( tampa( #et#a(! dndng dada
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Palpa! au!(ulta! pe#(u!
" Tda( te#dapat n2e# te(an " Sua#a na:a! R0n(& " !0n0#
. Jantung In!pe(! Palpa! au!(ulta! pe#(u!
" I7tu! 70#d! tda( te#l&at " pul!a! I7tu! ?0#d! te#a,a " S1 dan S- #egula# " Bata! +antung n0#mal
+. A,d0men In!pe(! Palpa!
au!(ulta! pe#(u!
" Tda( ada le!pe#ut tampa( (em,ung dan " Te#dapat !ed(t n2e# te(an pada ,agan Kuad#an tenga& ,a3a& tepatn2a d ,agan !mp!! " B!ng u!u! 1% >=ment " Supel tmpan
(. Genetala pa!en mengguna(an (atete#(eadaan (atete#(eadaan !(#0tum pa!en mem,eng(a( mem,eng(a( l. E(!t#emta! (anan (#
555 555 5 (ete#angan5 "5Te#pa!ang Te#pa!an 5g5n:u! 5 d tangan (#
1 8 6 4
;Rl -% tpm<
" T Tda( *am *amppu ,e# ,e#gge#a( !ama ama !e !e(al " Han2 Han2aa mamp mampuu meng mengge ge#a #a(( ((an an u+un u+ungg e(!t e(!t# #m mta ta!! " Han2a n2a mampu mengge!e e!e# !ed(t " *ampu *ampu meng mengge# ge#a( a((a (ann tan tanga gann deng dengan an ,ant ,antua uan n!a !aat at ,ant ,antua uann dlepa!(an tangan (ut +atu& " (e( (e(ua uatan tan 0t0t 0t0t !ed !ed( (tt ,e#( ,e#(u# u#an ang g mamp mampuu mel mela3 a3an an g#a9 g#a9ta ta! ! !e!aat lalu +atu& " Ke( Ke(uuatan atan 0t0t t0t mam mampu pu mela3 ela3an an g#a9 g#a9t ta! a!
$ Data P!(0l0g P!(0l0g! ! a. Statu! Em0! Klen me#a!a 7ema! dan tampa( !ed(t ta(ut dengan tnda(an ,eda& 2ang a(an dla(u(an ,. K0n!ep d# K0n!ep d# menu#un d(a#ena( p#0!e! pen2a(t
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7. Ga2a ,e#(0mun(a! Klen !ult da+a( ,e#(0mun(a! d. P0la Inte#a(! Inte#a(! (elua#ga dan +uga pa!en te#&am,at t e#&am,at d(a#ena(an p#0!e! pen2a(t.
$. Peme#(!aan 'a,0#at0#um ;-/)%$)1< a. GDP ,. RB?
" 6/ " 11 .
7. WB? d. H, H, e. H?T
" 18. 10 g= g=dl " 16 " 81- g=dl
6
10
g= g=dl
3
/. Te#ap *ed! -$)%$)1 Rnge# 'a(tat
-% tpm ;%% ml<
In+ De>ameta!0n
->1 amp=mg
In+ N090#apd
8 > 6 unt
In+ T#ane>d
8>1 amp ;% mg<
Am,#0>0l ;0#al<
8>1 !dt ;8% mg<
-/)%$)1 Rnge# 'a(tat -% tpm ;%% ml< In+ In+ De> De>am amet eta! a!0n 0n ->1 ->1 amp= amp=m mgg In+ N090#apd 8 > 6 unt In+ T#ane>d 8>1 amp ;% mg< Sal,utam0l - mg ;8 > 1 ta,< Te#ap Te#ap lan+ut " Gant D? ,a#u -)%$)1 In+ 7e:0ta>me
1 g#=/ +am
n0#mal " $%)16% " / ) 88 " 6%%%)11%%% " 1-) 1$ " 8) 6$ g=dl
32
Rnge# 'a(tat In+ In+ De> De>am amet eta! a!0n 0n In+ N090#apd In+ T#ane>d In+ (et0l0#a> In+ #antdn
B.
-% tpm ;%% ml< ->1 ->1 amp= amp=m mgg 8 > 6 unt 8>1 amp ;% mg< 8 > 1 amp= -ml 8> 1 amp= % mg
ANA'ISA DATA N O
DATA
ETIO'OGI
*ASA'AH
33
1
D!
" Klen mengata(an n2e#
d
,agan
!mp!! &alua#an u#n tda( lan7a#. " N2e# (et(a ,e#ge#a(
P
dan
,la
,agan
5
!mp! dte(an " Sepe#t Sepe#t dtu!u() dtu!u()
R
tu!u( " D ,agan ,agan a,d0me a,d0menn ,a3a& tepatn2a d
P#0!tat mem,e!a# Pen2emptan 'umen U#ete# P#0!tat(a O,!t#u(! I#ta! *u(0!a
N2e# A(ut A(ut
#ang!angan !2a#a: damete# (e7l Open gate 70nt#0l
,agan !mp!! dan meatu! u#etan2a. " !edang ;6)4< " Hlang tm,ul " Pa! Pa!en en tam tampa( pa(
S T D0
me#ng! Pa!en tampa( gel!a& Pa!en tampa( lema! TD " 16%=% mm&g N " /4 >=m RR " -/ >=m T " A:e,#! -.
D! " Pa!en meng engata( ta(an ,ngung
dan
meng menget eta& a&u u
tda( tent tentan angg
p#0!edu# pem,eda&an D0 " ) 3a+a& 3a+a& pa!e pa!enn tampa( tampa( )
tegang pa!en tampa( !e#ng
)
ma#a& ,la te#ganggu pa!en tampa( gel!a& dan dan !ult ult tdu tdu## !e+a !e+a( ( &a# peng(a+an
Cortex cerebri
!eri "iper#ep#ikan
!eri akut
pem,e!a#an p#0!tat pen2emptan lumen u#eta O,!t#u(! TURP Ku#ang In:0#ma!
pe#tama $n#ieta#
An!eta!
3%
)
pa!en tampa( tda( !ele#a
ma(an
dan
p0#! ma(an !e#ng 8.
tda( &a,!. D! " ) pa!en mengata(an mengata(an ne# (et(a Ba( Ba( tda( da( )
lan7a# 7a#
!uda&
le,& da# 1 ,ulan Pa!en mengata(an !e# !e#ng ng me#a me#a!a !a tda tda( (
pua! !etela& ,a(. D0 " ) Ta Tampa( mpa( te# te#pa pa!a !ang ng )
!elang (atete#. 90lume u#n &an2a 1%%)%% 77=&a#
Pem,e!a#an p#0!tat Pen2emptan lumen
Gangguan
u#eta
Elmna! U#n
O,!t#u(! Reten! u#n Gangguan elmna! u#n
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