ASUHAN KEPERAWATAN PADA NY. A DENGAN POST CHOLESISTECTOMY HARI KE 10 ATAS INDIKASI CHOLANGITIS DI RUANG KEMUNING 3 RSUP. DR HASAN SADIKIN BANDUNG
Daftar Isi:
- Karya tulis ini dilatarbelakangi oleh banyaknya komplikasi pasca operasi kandung empedu yang meliputi nyeri, ketidakseimbangan nutrisi, risiko infeksi, komplikasi dari penyakit yang mengakibatkan luka, komplikasi tirah baring akibat post operasi yang menjadi bahan monitor perawat. Pada saat pengkajian hari ke 10 post kolesistektomi, luka post op tampak kering, tidak ada tanda – tanda infeksi, terdapat nyeri di area luka post op, dengan skala nyeri 4. Gejala akibat dari kolangitis masih tampak ikterus, urine seperti teh, terdapat pitting edema. Tidak ditemukan tanda adanya komplikasi dari kolangitis ataupun pembedahan seperti pankreatitis, peritonitis. Dari hasil data tersebut diagnosa keperawatan yang muncul yaitu nyeri akut,ketidakseimbangan nutrisi kurang dari kebutuhan, kerusakan integritas kulit, intolerasi aktifitas, risiko infeksi, kesiapan meningkatkan religiolitas. Untuk mengatasi masalah nyeri penulis menentukan intervensi memonitor nyeri, monitor TTV, ajarkan teknik nafas dalam, ajakan doa mengatasi nyeri, kolaborasi pemberian obat nyeri, untuk mengatasi ketidakseimbangan nutrisi penulis menentukan intervensi memberikan penkes nutrisi sesuai kebutuhan yaitu diet cair, untuk mengatasi kerusakan integritas kulit penulis menentukan intervensi melakukan perawatan luka setiap harinya, untuk mengatasi intoleransi aktifitas penulis membantu penuhi perawatan diri secara total care, mobilisasi di tempat tidur secara bertahap, untuk mengatasi risiko infeksi penulis menentukan intervensi tingkatkan teknik cuci tangan, mengkaji penggunaan kateter, infus, drain, kolaborasi pemberian antibiotik, untuk masalah kesiapan meningkatkan religiolitas penulis menentukan intervensi memberikan penjelasan cara praktik ibadah,membimbing doa.-- This paper is motivated by the many complications after gallbladder surgery which include pain, nutritional imbalance, risk of infection, complications from diseases that cause wounds, complications of bed rest due to post surgery which are used as monitoring materials for nurses. At the time of the 10th day post-cholecystectomy assessment, the post-op wound looked dry, there were no signs of infection, there was pain in the post-op wound area, with a pain scale 4. Symptoms due to cholangitis still appear jaundice, urine like tea, there is pitting edema . There were no signs of complications from cholangitis or surgery such as pancreatitis, peritonitis. From the results of these data, nursing diagnoses that arise are acute pain, nutritional imbalance less than the need, damage to skin integrity, activity intolerance, risk of infection, readiness to increase religiosity. To overcome the problem of pain, the authors determined interventions to monitor pain, monitor TTV, teach deep breathing techniques, call for prayer to deal with pain, collaboration in providing pain medications, to overcome nutritional imbalances, the authors determined interventions to provide nutritional health as needed, namely a liquid diet, to overcome damage to the integrity of the author's skin determine the intervention to do wound care every day, to overcome the intolerance of the author's activities to help complete self-care in total care, to mobilize in bed gradually, to overcome the risk of infection the author determines the intervention to improve hand washing techniques, assess the use of catheters, infusions, drain, and collaborative administration antibiotics, for the problem of readiness to increase religiosity, the authors determine the intervention to provide an explanation of how to practice worship, guide prayer.