PERAWATAN WSD
PENDAHULUAN
Pemasangan kateter thorak merupakan prosedur drainase udara dan cairan dalam kavum pleura dengan pemasangan pipa melalui sela antar iga ke dalam kavum pleura.Pada orang normal, kavum pleura terisi oleh lapisan cairan tipis (cairan serousa) 4 ml yang berfungsi sebagai pelicin saat terjadi pergerakan paru, pada saat respirasi.Keberadaan cairan ini karena adanya keseimbangan antara produksi dan reabsorbsi.Pada keadaan pathologis keseimbangan ini dapat terganggu yang mengakibatkan tertumpuknya cairan dalam kavum pleura dalam jumlah yang banyak dengan manifestasi yang beragam, tergantung factor etiologi yang merusak keseimbangan tersebut. Adanya udara atau akumulasi cairan dalam kavum pleura akan mengganggu mekanisme ventilasi, menimbulkan gangguan fungsi kardiovaskuler dan memberikan keluhan subyektif berupa sesak nafas. Gejala tergantung jumlah dan kecepatan proses akumulasi udara atau cairan. Pemasangan kateter thorak untuk drainase kavum pleura, pertama kali diperkenalkan oleh Bullen pada tahun 1875.Satu tahun kemudian Croswell Hewett menggambarkan tehnik Drainase Empiema menggunakan pipa karet yang dimasukkan ke dalam kavum pleura dengan bantuan trokar.Tehnik ini baru digunakan secara luas pada tahun 1917. Setelah terbukti sukses dalam pengobatan empiema post influenza. Penggunaan tehnik drainase ini sangat mengurangi kasus kematian korban trauma thorak selama perang dunia kedua. Saat ini pemasangan kateter thorak telah dilakukan secara luas pada penderita dengan trauma thorak, pneumothorak, empiema, efusi pleura yang masiv dan chylothorak. Seperti tindakan invasif lainnya, pemasangan kateter juga dapat menimbulkan komplikasi yang tidak diharapkan. Dengan indikasi yang tepat, menggunakan
tehnik yang benar serta
memberikan perawatan pasca pemasangan secara baik, kita dapat menghindarkan penderita dari komplikasi yang tidak diharapkan.
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A. PENGERTIAN
WSD adalah sebuah kateter yang diinsersi melalui thoraks untuk mengeluarkan udara dan cairan.( Potter& Perry, 2006 ) WSD adalah tindakan pemasangan kateter kedalam rongga thoraks dengan tujuan untuk mengambil cairan dengan viskositas yang tinggi ataupun darah, nanah maupun udara pada pneumothorak dan menghubungkannya dengan water seal drainage. (Prof. Dr. H. Tabrani Rab, 1998) WSD merupakan tindakan invasive yang dilakukan untuk mengeluarkan udara, cairan (darah,pus) dari rongga pleura, rongga thorax; dan mediastinum dengan menggunakan pipa penghubung.(http://www.scribd.com/doc/17350662/Water-Seal-Drainage) Jadi kesimpulannya WSD adalah tindakan invasif yang dilakukan untuk mengeluarkan udara, cairan (darah,pus) dari rongga thorak , rongga pleura, dan mediastinum dengan cara memasukkan selang atau tube ( pipa penghubung ) melalui atau menembus muskulus interkostalis ke dalam rongga thoraks dan menghubungkannya dengan water seal drainage. B. ORGAN-ORGAN YANG TERLIBAT DALAM TINDAKAN
Bila kita membicarakan organ tubuh yang terlibat dalam tindakan WSD, maka kita harus membahas tentang organ sistem pernafasan, termasuk didalamnya anatomi dan fisiologi sistem pernafasan. Paru merupakan organ yang memegang memega ng peranan penting dalam menentukan ada atau tidaknya
indikasi
maupun
kontra
indikasi
dari
pemasangan
WSD
pada
pasien.
Paru-paru terletak di kedua sisi jantung di dalam rongga dada dan dikelilingi serta dilindungi oleh sangkar iga.Bagian dasar setiap paru terletak di atas diafragma; bagian apeks paru (ujung superior) terletak setinggi klavikula.Pada permukaan tengah dari setiap paru terdapat identasi yang disebut hilus, tempat bronkhus primer dan masuknya arteri serta vena pulmonari ke dalam paru.Bagian kanan dan kiri paru terdiri atas percabangan saluran yang membentuk pohon bronkhial, jutaan alveoli dan jaring-jaring kapilernya, dan jaringan ikat.Sebagai organ, fungsi
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(Gbr. 1-6).Lapisan yang membatasi antara lobus disebut fisura.Setiap lobus dipasok oleh cabang utama percabangan bronkhial dan diselaputi oleh jaringan ikat.
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Lobus kemudian membagi lagi menjadi kompartemen yang lebih kecil dan dikenal sebagai segmen.Setiap segmen terdiri atas banyak lobulus, yang masing-masing mempunyai bronkhiole, arteriole, venula, dan pembuluh limfatik.Dua lapis membran serosa mengelilingi setiap paru dan disebut sebagai pleurae.Lapisan terluar disebut pleura parietal yang melapisi dinding dada dan mediastinum.Lapisan dalamnya disebut pleura viseral yang mengelilingi paru dan dengan kuat melekat pada permukaan luarnya.Rongga pleural ini mengandung cairan yang dihasilkan oleh sel-sel serosa di dalam pleura.Cairan pleural melicinkan permukaan kedua membran pleura untuk mengurangi gesekan ketika paru-paru mengembang dan berkontraksi selama bernapas. Jika cairan yang dihasilkan berkurang atau membran pleura membengkak, akan terjadi suatu kondisi yang disebut pleurisi dan terasa sangat nyeri karena membran pleural saling bergesekan satu sama lain ketika bernapas.Paru berada dalam rongga pleura yang tekanannya selalu negatif selama siklus nafas (tekanan udara di luar dianggap = 0). Paru mengembang sampai menempel pleura. Bila tekanan rongga pleura jadi positif, paru-paru akan collaps. Rongga toraks terdiri atas rongga pleura kanan dan kiri dan bagian tengah yang disebut mediastinum. Jaringan fibrosa membentuk dinding sekeliling mediastinum, yang secara sempurna memisahkannya dari rongga pleura kanan, dimana terletak paru kanan, dan dari rongga pleura kiri, yang merupakan tempat dari paru p aru kiri. Satu-satunya organ dalam rongga toraks yang tidak terletak didalam mediastinum adalah paru-paru.Toraks mempunyai peranan penting dalam pernapasan. Karena bentuk clips dari tulang rusuk dan sudut perlekatannya ke tulang belakang, toraks menjadi lebih besar ketika dada dibusungkan dan menjadi lebih kecil ketika dikempiskan. Bahkan perubahan yang lebih besar lagi terjadiketika diafragma berkontraksi dan relaksasi. Saat diafragma berkontraksi, diafragma akan mendatar keluar dan dengan demikian menarik dasar rongga toraks ke arah bawah sehingga memperbesar volume toraks. Ketika diafragma rileks, diafragma kembali ke bentuk awalnya yang seperti kubah sehingga memperkecil volume rongga toraks. Perubahan dalam ukuran toraks inilah yang memungkinkan terjadinya proses inspirasi dan ekspirasi.
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perbedaan tekanan ini (tekanan gradien) menyebabkan cairan mengalir atau berpindah.Cairan selalu mengalir dari tempat dengan tekanan yang tinggi ke tempat dengan tekanan yang lebih rendah. Dalam kondisi standar, udara atmosfir mengeluarkan tekanan 760 mm Hg. Udara dalam alveoli pada akhir satu ekspirasi dan sebelum dimulai inspirasi berikutnya juga mengeluarkan tekanan 760 mm Hg. Itulah sebabnya pada titik ini, udara tidak memasuki dan tidak meninggalkan paru-paru. Mekanisme yang menyebabkan ventilasi pulmonal adalah mekanisme yang menimbulkan tekanan gradien antara udara atmosfir dan udara alveolar. Mekanisme ventilasi
disajikan
secara
singkat
pada
Gambarberikut
:
Pada keadaan pathologis dimana tekanan intra pulmonal yang lebih tinggi dari pada tekanan intra thoracal, udara dari intra pulmonal dapat mengalir ke dalam pleura.Keadaan ini disebut pneumothorak yang merupakan salah satu indikasi pemasangan WSD. Organ tubuh lain yang terlibat langsung dalam tindakan ini adalah organ-organ yang terlibat pada lokasi pemasangan tube WSD. Lokasi pemasangan WSD menunjukkan jenis drainase yang diharapkan. Organ-organ yang terlibat pada lokasi pemasangan adalah : 1. Apikal : Linea Medio Clavicularis ( MCL ) pada ruang antar iga II – II – III III ( Monaldi ), dimana selang dimasukkan secara anterolateral, fungsinya : untuk mengeluarkan udara dari rongga pleura, diperlukan pada kasus pneumothoraks. Karena udara naik, selang dada (tube) ini diletakkan tinggi, sehingga evakuasi udara dari ruang dan
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juga sumber lain yang menyebutkan ruang kelima atau keenam ruang interkostal, posterior atau lateral.Fungsi
untuk
mengeluarkan
cairan
(darah,
pus) dari
ronggapleura.Cairan di dalam ruang intrapleural dipengaruhi oleh gravitasi dan lokalisasi di bagian bawah rongga paru-paru ketika klien duduk tegak. 3. Mediastinal : dipasang pada daerah mediastinum, mediastinum mediastinum dan terhubung ke sistem drainasegunanya mengeluarkan darah atau cairan untuk pencegahan akumulasi di seluruh jantung. Mediastinal Mediastinal tube biasanya digunakan setelah operasi jantung terbuka. Gambar lokasi :
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C. INDIKASI DAN KONTRA INDIKASI PEMASANGAN I. Indikasi Pemasangan
1. Pneumothoraks Adalah pengumpulan udara atau gas lain dalam ruang pleura. Gas menyebabkan paru menjadi kolaps karena gas tersebut menghilangkan tekanan negatif intrapleura dan suatu tekanan ( counterpressure ) yang diberikan untuk melawan
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pneumothoraks yang meningkat. Untuk mencegah terjadinya sesak nafas berat yang disebabkan oleh karena meningginya tekanan intratorak, maka diperlukan pemasangan WSD. Ada pula pendapat yang mengatakan bahwa terdapatnya pneumotorak yang besar merupakan indikasi perlunya pemasangan WSD. Hal ini atas pertimbangan bahwa paru akan tetap menguncup dalam waktu yang cukup lama. Beberapa kasus pneumothoraks yang termasuk indikasi pemasangan WSD adalah : a. Pneumothoraks tension Pemasangan kateter pada keadaan ini harus dilakukan secepat mungkin.Pada keadaan darurat dekompresi dapat dilakukan dengan insersi jarum besar ke dalam kavum pleura melalui intercosta II anterior. Tindakan
ini
akan
mengubah
tension
pneumothorak
menjadi
pneumothorak. b. Pneumothoraks totalis Pemasangan kateter thorak pada keadaan ini ini tetap dilakukan meskipun tanpa tanda-tanda sesak. c. Pneumothoraks parsial Pneumothoraks parsial dengan kolaps paru lebih dari 20% perlu pemasangan kateter thorak.Sedangkan pada pneumothorak parsial dengan kolaps paru kurang dari 20% tanpa gejala ataupun penyakit dasar, perawatan dapat dilakukan secara konservatif.Prosentase kolaps merupakan perbandingan antara luas bagian paru yang kolaps dengan
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e. Pneumothoraks bilateral Untuk keadaan ini juga merupakan indikasi pemasangan kateter thorak. Biasanya diikuti tindakan thorakotomi
2. Hemathoraks Merupakan akumulasi darah dan cairan di dalam rongga pleura di antara pleura parietal dan pleura viseral, biasanya merupakan akibat trauma. Hemathoraks
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merupakan indikasi pemasangan kateter thorak.
Evakuasi darah pada
hemathoraks masiv (lebih dari 2000 cc) harus diawali dengan penggantian cairan atau darah. Hemathoraks yang termasuk dalam indikasi pemasangan kateter thoraks adalah Hematothoraks bilateral, Hemato-pneumothoraks. Pemasangan kateter thoraks untuk mencegah pembentukkan bekuan darah dalam kavum pleura dan untuk memonitor kemungkinan berlanjutnya perdarahan.
3. Kilotoraks Suatu keadaan dimana terdapatnya cairan limfa di pleura. Warna cairan ini seperti
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penyebab yang nontrauma, terutama disebabkan oleh kelainan dari duktus toraksikus dan keadaan ini merupakan 50-60% dari kasus dibandingkan dengan yang trauma, yakni hanya 10-40% dari kasus.Sedangkan pada yang nontrauma, terutama disebabkan oleh congenital, yakni fistula antara duktus toraksikus dengan pleura.Tumor limfoma, fibrosis mediastinum, limfangiomiomatosis pulmonal, keseluruhannya dapat menyebabkan terjadinya kilotorak. Tindakan pemasangan WSD dengan pipa yang mutipel (multiple tube) hasilnya akan tergantung kepada ada tidaknya perlengketan pleura dan tertutupnya duktus. Kilotoraks Chylothoraks sulit diterapi, meskipun dengan pemasangan kateter thorak
dan
disertai
pleurodesis.
Penyebab
chylothoraks
adalah
trauma,
malignansi, abnormalitas kongenital. 4. Empiema Empiema thoracis setelah dipungsi tidak berhasil atau pus sangat kental, sehingga perlu dipasang WSD dengan chest tube yang besar, kadang harus dilakukan reseksi iga.
Cairan empiema perlu didrainase secepatnya dan sebanyak-
banyaknya, untuk mengurangi gejala toksis dan mempercepat resolusi proses inflamasi. Pada fase akut, permukaan paru masih fleksibel dan akan mengembang sempurna setelah cairan empiema di drainase sampai habis. Keterlambatan drainase sering perlu diikuti dekortikosi, karena terbentuk peel pada permukaan paru. Kilotoraks Hampir setiap operasi thorakotomi perlu diikuti pemasangan kateter thorak.
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melakukan pemeriksaan sitologi.Indikasi pemasangan kateter thorak pada efusi pleura non maligna masih controversial.Keuntungan dari tindakan ini tidak seimbang dengan komplikasi yang mungkin terjadi, misalnya pendarahan dan infeksi sekunder. 6. Flail chest ,adalah akibat dari trauma pada thorax, disebabkan oleh gangguan struktur semirigid secara normal pada tulang dada,disebabkan dari: (1). Fraktur pada tiga atau lebih l ebih sendi send i iga pada satu atau lebih lokasi, (2). Fraktur iga dengan terpisahnya kostokondral atau (3). Fraktur sentral. Dimanapun fraktur terjadi, segmen tersebut kehilangan kontuinitasnya dengan dinding dada yang masih utuh dan terjadi gerakan paradoksial. Selama inspirasi, tekanan intrapleural pada sisi sehat lebih besar, sehingga merubah posisi mediastinum kearahnya. Sebaliknya selama ekspirasi tekanan negative pada sisi sehat kurang dari yang sakit dan mediastinum miring ke arah sisi yang sehat. Kejadian ini diketahui sebagai flutter mediastinal, selanjutnya mengganggu ventilasi dan curah jantun g. 7. Fluidothoraks yang hebat, karena adanya cairan yang banyak menyebabkan pasien Sesak
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-
Bullosa paru
-
Pasien dengan PEEP ( Positive End Expiratory Pressure )
-
Pasien dengan satu paru
-
Pasien dengan hemidiafragma, effusion pleura dan splenomegali
D. KONSEP FISIOLOGIS TINDAKAN ATAU ALAT TERHADAP TUBUH
Paru merupakan organ elastis yang berbentuk kerucut yang terletak di rongga dada. Kedua paru saling terpisah oleh mediastinum ditengahnya. Didalam mediastinum terdapat jantung dan pembuluh darah besar, arteri pulmonalis, arteri bronchialis bronchioli, saraf, pembuluh limfe, masuk pada kedua paru. Pada bagian hilus terdapat akar paru. Paru diselimuti oleh membrane tipis, licin yang disebut pleura. Pleura ada dua yaitu pleura parietalis yang melapisi rongga thorak. Pleura visceralis yang melapisi paru. Di antara kedua pleura tersebut ada cairan dengan volume total 4 ml bertindak sebagai pelumas antara pleural viseral dan parietal, memungkinkan cairan itu bergerak dengan halus tiap kali bernafas. Karena dua lapisan pleural
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Semua gas-gas bergerak dari area dengan tekanan lebih tinggi ke tekanan yang lebih rendah. Selama inspirasi, rongga dada membesar karena kontraksi diafragma. Ini meningkatkan area paru dan menyebabkan tekanan intrapleural turun sampai di bawah tekanan atmosfir. Aliran udara dari tekanan atmosfir relatif tinggi ke area tekanan t ekanan rendah di paru. Selama ekspirasi, proses ini kebalikannya. Rekoil diafragma, menurunkan area dalam rongga dada dan menekan paru paru. Tekanan intrapleural kini lebih tinggi daripada tekanan atmosfir, menyebabkan udara bergerak keluar paru-paru. Setelah otot pernafasan rileks, tekanan antara udara luar dan paru sama (760 mmHg pada permukaan laut). Karena tekanan sama, maka tak ada udara bergerak. Ada
3
faktor
yang
mempertahankan
tekanan
negatif
yang
normal
ini.Pertama,
jaringan elastik paru memberikan kekuatan kontinu yang cenderung cend erung menarik paru menjauh dari rangka toraks tetapi permukaan pleura viseralis dan pleura parietalis yang saling menempel itu tidak dapat dipisahkan, sehingga tetap ada kekuatan kontinue ysng cenderung memisahkannya, kekuatan ini dikenal sebagai tekanan negatif diruang pleura.Tekanan intrapleura secara terusmenerus
bervariasi
sepanjang
siklus
pernafasan
tapi
selalu
negatif.
Faktor utama kedua dalam mempertahankan tekanan negatif intrapleura adalah kekuatan osmotik
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lokasi yang berbeda tergantung tujuan selang. Semua selang dada ditangani sebagai selang intrapleural untuk keamanan pasien. Selang yang lebih besar (20-36 french) digunakan untuk mengalirkan darah atau drainage pleural yang kental. Selang yang lebih kecil (16-20 french) digunakan untuk membuang udara. Selang dada bekerja sebagai drain untuk udara dan cairan. Untuk membuat tekanan negatif intrapleural, sebuah segel diperlukan pada selang dada untuk mencegah udara luar masuk ke sistem. Cara paling sederhana untuk melakukan ini yaitu dengan menggunakan sistem drainage dalam air. Tinjauan tentang sistem satu-dua-tiga-botol memberikan
dasar
pemahaman
semua
produk
botol
yang
dijual.
Setiap
sistem
mempunyaikeuntungan dan kerugian. Pengetahuan terhadap sistem ini memungkinkan perawat untuk mengatur dengan aman sistem drainage selang dada yang paling kompleks sekalipun.Pemasangan WSD akan menimbulkan beberapa efek pada pasien, antara lain: 1. Nyeri pada daerah dada dan bahkan menyebar keseluruh tubuh terutama pada daerah insisi 2. Irama jantung tidak teratur / aritmia 3. Mengalami kesulitan bernapas ( dyspnea d yspnea ) dan kesulitan saat batuk
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3. Infeksi local, empiema dan osteomyelitis dapat timbul akibat tindakan yang tidak aseptic. Dengan kateter yang steril dan dengan yang terpasang baik, maka infeksi jarang terjadi. Akan tetapi apabila drain tersumbat, maka sangat mudah terinfeksi. Oleh karena itu bila jumlah cairan yang keluar dibawah 50 cc, maka drai harus dicabut dari rongga pleura, oleh karena selain cairan sudah tidak ada, juga mudah menyebabkan terjadinya infeksi Infeksi local Keadaan ini timbul akibat pengembangan paru yang berlangsung terlalu cepat. Umumnya terjadi pada keadaan dimana kolaps paru sudah berlangsung lebih dari 72 jam dan penggunaan hisapan kontinyu yang terlalu dini. Komplikasi ini juga dapat timbul tanpa pengguanaan hisapan kontinyu. 4. Emphysema kutis, sering terjadi pada orang tua yang elastisitas kulitnya mulai menurun 5. Kegagalan pengembangan paru Kegagalan pengembangan paru pada pneumo thorax dapat disebabkan oleh kesalahan letak kateter, lubang drainage kateter keluar dari kavum pleura, kebocoran udara yang menetap atau akibat sumbatan pada bronkus. Pada empiema biasanya disebabkan oleh terbentuknya peel pada permukaan paru 6. Kateter yang tertekuk atau tersumbat oleh bekuan darah dan pus yang kental
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Salah satu dari komplikasi pemasangan WSD adalah resiko terjadinya infeksi. Untuk itu perlu diperhatikan beberapa prinsip bagi perawat sebelum, saat, sesudah tindakan WSD maupun saat pencabutan selang WSD : 1. Pada tindakan pemasangan WSD menggunakan prosedur yang benar dengan tetap memperhatikan tehnik sterilitas, misalnya dengan penggunaan prinsip universal precause (cuci tangan, handschoen, masker, pakaian kerja dan topi). Pergunakan alat-alat steril, Bersihkan daerah yang akan dilakukan pemasangan WSD dengan antiseptic. Tujuannya untuk mencegah masuknya microorganime yang dapat menimbulkan infeksi sekunder. 2. Pertahankan lingkungan aseptic selama pemasangan alat
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SISTEM
MEKANISME
KEUNTUNGAN
KERUGIAN
KERJA Sistem
water-seal
botol tunggal
Terdiri dari 1 botol dengan penutup segel. Penutup
mempunyai
2 lubang selang yaitu 1
untuk
ventilasi
Air steril dimasukan Penyusunan
paling Saat
drainage
dada
ke dalam botol sampai sederhana.
mengisi botol, lebih
ujung selang terendam
banyak
2 cm untuk mencegah masuknya dalam
udara
tabung
menyebabkan
ke
yang kolaps
Mudah untuk pasien yang dapat berjalan
kekuatan
diperlukan
untuk
memungkinkan udara dan
cairan
pleural
untuk keluar dari dada masuk ke botol.
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cairan
dari
ruang
pleural
tetapi
tidak
memungkinkan udara untuk
menjadi bagi
lebih
udara
sulit untuk
keluar dari dada.
mengalir
kembali ke dada.
Hasilnya tidak banyak yang dapat ditampung
Selang untuk ventilasi dalam botol dibiarkan terbuka
untuk
memfasilitasi
udara
Efektivitas penghisapan
dari dengan
satu botol kurang
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pneumothoraks Sistem
water-seal
dua-botol
Cairan drainase dari Dengan cara ini baik Menambah area mati rongga pleura masuk udara maupun cairan pada system drainage ke botol 1 dan udara lebih mudah terhisap yang
Digunakan 2 botol ; 1 botol mengumpulkan cairan drainage dan
dari
rongga
pleura bersama-sama, karena potensial untuk masuk
masuk ke water seal pada botol yang kedu a ke dalam area pleural botol 2
selain
botol ke-2 botol b otol water seal
mempunyai
mengalirkan Prinsip
kerja
sama
dengan sistem 1 botol
negative berfungsi
berfungsi tekanan juga sebagai
Untuk
terjadinya
aliran, tekanan pleural harus lebih tinggi dari
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Sistem
water-seal
Digunakan
mengeluarkan volume untuk
tiga-botol
udara Sama dengan sistem 2 botol,
ditambah
botol mengontrol
untuk System paling aman Lebih kompleks, lebih
1
atau
dengan
cairan penghisapan pengisap
pengontrol
untuk jumlah Pada system ini, yang
mengatur banyak untuk
kesempatan terjadinya
kesalahan
dalam
perakitan
dan
pemeliharaan
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dan
terbuka
atmosfer
ke system
ini
dikendalikan botol
oleh
manometer.
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dicelupkan, udara luar akan terisap ke dalam system.
Hal
ini
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selang dan maneuver yang kesulitan
mengatasi akan
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dengan kasa steril
Cara mengganti botol WSD:
1. Siapkan set yang baru Botol berisi cairan aquadest ditambah desinfektan 2. Selang wsd di klem dulu 3. Ganti botol wsd dan lepas kembali klem 4. Amati undulasi dalam slang wsd N. PENDIDIKAN YANG PERLU DIBERIKAN PADA PASIEN DAN KELUARGA
1. Beritahukan pasien dan keluarga tentang prosedur, tujuan, akibat dan perawatan mengenai system drainage 2. Anjurkan pasien dan keluarga untuk segera melaporkan setiap perubahan yang terjadi 3. Pada pediatric pertimbangkan:
jika mungkin, menggunakan gambar dan boneka khusus, membiasakan anak dan keluarga
dengan
peralatan
sebelum
menyisipkan
sistem
drainase
dada
(Hockenberry dan lain-lain, 2003)
Biarkan anak bermain dengan peralatan dan boneka khusus sebelum menyisipkan system drainase dada
Drainase selang dada lebih dari 3 ml / kg / jam selama lebih dari 2 jam berturutturut adalah berlebihan dan mungkin menunjukkan perdarahan pascabedah (Hockenberry dan lain-lain, 2003).
4. Pada gerontology Kerapuhan dari kulit orang dewasa yang lebih tua memerlukan perawatan khusus dan perencanaan untuk pengelolaan ganti tabung dada. Sering terdapatnya kerusakan kulit di sekitarnya (Lueckenotte, 2000) 5. Pertimbangan rawat di rumah
tanda-tanda
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pengisap
dan
menggunakan
mekanis
katupsatu-arahbukannya
ruang
airsegel(Carroll,2002)
Anjurkan klien bagaimana ambulate dan tetap aktif dengan perawatan sistem drainaseselangdadadirumah
Klien dan keluarga cepat memberikan informasi mengenai perubahan dalam sistem drainase kepada profesional perawatan (misalnya nyeri dada, sesak napas, perubahan warna atau jumlah drainase)
O. EVIDENCE BASE
1. Ada dan terus menjadi kontroversi mengenai stripping atau milking pada selang tabungdada. Stripping atau milking selang tabung dadaadalah proses yang digunakan untuk membersihkan gumpalan. Stripping atau milking dilakukan ketika perawat secara manual menekan dan memeras selang tabung dada , dan upaya untuk memindahkan tabung drainase dada menuju ke botol penampung. Teknik ini tidak boleh dilakukan secara rutin. Ketika occlusions karena terjadi penggumpalan darah, literatur bertentangan mengenai intervensi.Parkin (2002) mencatat berbagai praktek mengenai tabung dada milking atau stripping.Idealnya tabung harus diubah jika penyumbatan terdeteksi (Allibone, 2003).Namun, dalam beberapa pilih situasi, misalnya dengan operasi dada pascaoperasi awal, hal itu mungkin diperlukan untuk membersihkan tabung gumpalan darah.Dalam situasi ini milking atau stripping dari tabung dada dilakukan oleh perawat berpengalaman yang mengikuti panduan khusus.Bahaya stripping atau milking dada tabung adalah peningkatan mendadak tekanan hisap, yang pada gilirannya dapat menyebabkan cedera paru-paru atau melukai daerah operasi.Namun, tidak berfungsi tabung dada dapat menyebabkan masalah yang lebih parah, dan milking tabung dada mungkin satu-satunya pilihan (Parkins, 2002). 2. Penggunaan Nacl pada air di botol, masih dibicarakan. Alasannya karena Nacl merupakan cairan yang fisiologis, jika terjadi aspirasi Nacl mudah diserap dan tidak
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3. Saat ini sudah banyak digunakan trokar dan kateter yang disediakan dalam satu set yang steril dan sekali pakai (disposable). Terbuat dari plastic tidak mudah pecah, lebih aman karena system ini sel-contained tidak dapat dipisah dan terlepas, yang mungkin bisa terjadi pada sytem WSD memakai botol. Disamping itu dapat memfasilitasi transfuse mandiri (autotransfusi). Mencegah kesulitan dan mengurangi resiko komplikasi pada pasien dan keluarga yang pemahaman dan pengetahuannya
tentang dasar-dasar
pelaksanaan selang masih kurang. Kemudahan juga ju ga bagi perawat pe rawat dalam pemberian askep dan pada saat ambulasi.
Tetapi harganya mahal dan kehilangan water seal dan
keakuratan pengukuran drainage bila unit terbalik. (Tabrani, 1998).
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DAFTAR PUSTAKA
Budi Santosa, 2005, Panduan Diagnosa Keperawatan NANDA 2005-2006, Jakarta : Prima Medika Carpenito L.J, 2000, Buku 2000, Buku Saku Diagnosa Keperawatan, Keperawatan, Edisi 8, Jakarta : EGC. Hudak & Gallo, 1997, Keperawatan 1997, Keperawatan Kritis : Pendekatan Holistik , Volume 1, Edisi VI, Jakarta : EGC. Potter & Perry, 2002, Buku Ajar Fundamental Keperawatan : Konsep, Proses, dan Praktik Volume 2, 2, Edisi 4, Jakarta: EGC Suzanne C. Smeltzer & Brenda G. Bare, 2001, Buku Ajar Keperawatan Medikal Bedah Brunner & Suddarth, Edisi 8, Jakarta : EGC. Tabrani Rab,1996, Ilmu Rab,1996, Ilmu Penyakit Paru, Bandung: Hipokrates Tabrani Rab, 1998, Agenda 1998, Agenda Gawat Darurat (Critical Care), Care), Bandung: Alumni Wilkinson Judith, 2007, Buku 2007, Buku Saku Keperawatan, Keperawatan, Edisi 7, Jakarta: EGC http://indonesiannursing.com/2008/07/30/water-seal-drainage-wsd/ http://contoh-askep.blogspot.com/2008/08/water-seal-drainage-wsd.html http://bedahumum.wordpress.com/2008/12/21/pemasangan-pipa-intratorakal-atau-water-sealdrainase-wsd/ http://tikagemini.blogspot.com/2009/06/perawatan-water-seal-drainase.html http://rofiqahmad.wordpress.com/2008/01/29/water-seal-drainage/ http://radit11.wordpress.com/2009/05/19/trauma-thorax/ http://images.google.co.id/imgres?imgurl=http://nursecerdas.files.wordpress.com/2009/01/gbr19. jpg&imgrefurl=http://nursecerdas.wordpress.com/2009/01/12/sistem jpg&imgrefurl=http://nursecer das.wordpress.com/2009/01/12/sistem pernapasan/&usg=__DwsOQr6oV1C4wGiLG74n5tF48W0=&h=575&w=588&sz=40&hl=id&st art=16&um=1&itbs=1&tbnid=2REKvzu2jNllwM:&tbnh=132&tbnw=135&prev=/images%3Fq