Asuhan Keperawatan Klien

dengan Gagal Ginjal Kronik

Lestari Sukmarini, MNS

KMB FIK 2008

tanggal upload : 29 April 2009

Gagal ginjal kronik ?
Definisi GGK (CKD)
Ketidakmampuan ginjal mempertahankan
keseimbangan internal tubuh karena
penurunan fungsi ginjal bertahap diikuti
penumpukan sisa metabolisme protein dan
ketidakseimbangan cairan elektrolit.

gg. Fungsi excretory & non excretory
Fungsi ginjal?
Fungsi ginjal:
Regulasi volume cairan tubuh
Regulasi keseimbangan elektrolit
Regulasi keseimbangan asam basa
Regulasi tekanan darah (RAA)
Ekskresi sampah metabolik
Regulasi erithropoesis
Metabolisme vit D
Sintesis prostaglandin
Penyebab
Glomerulonefritis (GN)
Penyakit ginjal
herediter
Hipertensi
Uropathy obstruktif
Infeksi
Nefropati diabetik
 ALGORITMA GGK
ETIOLOGI

GFR
Restrisi air,
Hipertrofi sel renal Retensi air: edema, diuretik
Sodium reabsorbsi hipertensi, HF
antikonvulsant
Gg konsentrasi urin Eksresi sisa metabolik Uremia: kejang, BUN Cr

Restrisi K, K
Ekskresi kalium hiperkalemia binding agent
Fungsi ginjal lanjut P binding
Ekskresi phospat hiperphospatemia agent

Gg fungsi ekskretori
ekskresi H+ Asidosis metabolik NaHCO3

gg. fungsi
non- gg. reproduksi Libido & infertil
ekskretori
Gg imun Infeksi, penyembuhan luka lambat

Produksi eritropoetin Anemia, pallor

Gg absorpsi calcium Osteodistrofi, hipocalcemia

 PATOGENESIS OSTEODISTROFI RENAL

GAGAL GINJAL KRONIK

Ggn sistem regulasi Ggn faal ekskresi

akibat masa ginjal

1,25 (OH)2O3 Toksin uremia H+ plasma Fosfor plasma

Absorbsi Ca++ Buffer Ca++ Ca++ plasma

pada usus tulang

Hiperparatiroidism
Ca++ plasma
Menghambat Demineralisasi
efek vit D

Cadangan untuk
kalsifikasi tulang OSTEITIS FIBROSA

OSTEODISTROFI
 KLASIFIKASI GGK/CKD

Tahap Deskripsi GFR

1 Kerusakan ginjal 90
dg GFR N/

2 Kerusakan ginjal 60-89

GFR ringan

3 GFR sedang 30-59

4 GFR berat 15-29

5 Gagal ginjal <15

 Gambaran klinis

Kelainan hemopoesis:
anemia retensi toksin uremia
defisiensi eritropoetin
Kelainan sal. cerna: mual, muntah, hiccup, stomatitis, fetor
uremikum. ----
Kelainan mata: visus, retina, saraf mata.
Kulit: kering bersisik, gatal, uremic frost, easy bruishing.
Neurologi: kejang ec. Imbalans elektrolit, uremik
Kardiopulmonal: CHF, hipertensi, perikarditis, edema paru.
 Pemeriksaan diagnostik

Laboratorium
Analisa urin & kultur

Ureum, kreatinin serum,

CCT (fungsi ginjal)

Hemopoesis: Hb, Ht, faktor

pembekuan.
Elektrolit, AGD

Penunjang :
Foto polos abdomen

USG renogram

Pielografi retrograde
 PENGKAJIAN KEPERAWATAN

Riwayat kesehatan : faktor resiko (mengalami infeksi saluran nafas atas,

infeksi kulit, infeksi saluran kemih, hepatitis, riwayat penggunaan obat
nefrotoksik, riwayat keluarga dengan penyakit polikistik, keganasan,
nefritis herediter).
Sirkulasi : hipertensi, disritmia kardia, distensi vena jugular, edema general
(termasuk area periorbital, sakrum), pallor.
Eliminasi : perubahan pola urin, perubahan warna urin seperti merah,
keruh, pekat, oliguri.
Makanan/cairan : penambahan berat badan (edema), dehidrasi, mual,
muntah, adanya penggunaan diuretik, perubahan turgor kulit, edema.
Nyeri : pada area kostovertebral/pinggang
Pernafasan : dispnea, takipnea, adanya batuk produktif (edema paru),
kussmaul
Pemeriksaan diagnostik :
Sedimen urin : pengumpulan urin 24 jam untuk pemeriksaan bersihan
kreatinin dan protein total untuk memperhitungkan fungsi ginjal residual
dan ekskresi protein urin.
Biopsi ginjal sangat diperlukan untuk menentukan kelainan histologi
yang terjadi.

Darah : Hb karena anemia, BUN-creatinin , protein albumin serum

, potasium , AGD (as met).

Pemeriksaan lain yang penting adalah : ureum serum, albumin,

kolesterol, elektrolit dan juga pemeriksaan serologis seperti:
autoantibodi, complement C3 C4, imunoglobulin.

Urin: jumlah urin <400 cc/24jam; warna urin merah ditemukan adanya
hematuria gross/mikroskopik, proteinuria (rendah 1-2+; tinggi 3-4+),
cast merah selular menandakan adanya infeksi glomerular.
Bersihan creatinin mungkin .

Radiografi/USG: pembesaran/mengecil ginjal; batu/obstruksi.

Masalah perawatan utama
Kelebihan volume cairan tubuh
Ketidakseimbangan asam basa & elektrolit
Gg. Nutrisi: kurang dari kebutuhan
Aktivitas intoleran
Resti cidera
Gangguan koping
Kurang pengetahuan
Manajemen keperawatan
Prioritas intervensi
Monitor status cairan: observasi BB, edema, turgor kulit, dan
lakukan balans cairan (Intake-Output)
Monitor tanda vital dan tingkat kesadaran.

Monitor gejala uremik

Monitor pemeriksaan lab: fungsi ginjal, elektrolit, AGD, protein

albumin, Hb, Ht, trombo.
Optimalkan istirahat

Motivasi makan diet rendah protein

Pemberian makan dalam porsi kecil sering

Perawatan kulit dan pertahankan self hygiene

Psychosocial care: gali persepsi dan perasaan klien b.d penyakit

dan diskusikan ttg kondisi klien.
 Manajemen konservatif
Prinsip
Mencegah memburuknya fungsi ginjal
Cegah obat nefrotoksik
Cegah deplesi volume cairan ekstrasel
Cegah imbalans elektrolit
Restriksi ketat diet protein
Hindari penggunaan media kontras pemeriksaan tertentu

Pendekatan terhadap penurunan fungsi ginjal progresif lambat

Mengurangi gejala uremia
Koreksi faktor reversibel
Pengobatan tepat
Kontrol hipertensi
Cegah infeksi
Pendidikan kesehatan
Manajemen diet
 Dietary guidelines:
Restriksi Protein restriction: memperlambat progress.

Pertahankan kondisi optimal

Mengurangi/mencegah akumulasi toksin
azotemia
Mencegah pemburukan fungsi ginjal krn
glomerulosklerosis
Konsumsi protein hewani (AA esensial)
GGK ringan (LFG 70 ml/mnt)
Tanpa penurunan progresif DRP 1-1.2 gr/kg/hr
Penurunan progresif DRP 0.5-0.6 gr/kg/hr
GGK moderate (LFG 25-70) dan GGK lanjut DRP 0.5-
0.6 gr/kg/hr
 Restriksi garam: 46 gram/hari cegah retensi cairan &
kontrol hipertensi.
Restriksi cairan : cegah progress CKD.
Restriksi Potassium : tahap lanjut ginjal tidak mampu
membuang potassium = hiperkalemia abnormal heart
rhythms.
Restriksi Phosphor: melindungi tulang.
Terapi lain : - dialisa
- transplantasi
 DIALISIS
General Principal: Movement of fluid and molecules
across a semi permeable membrane from one
compartment to another

Hemodialysis Move substances from blood through

a semi permeable membrane and into a dialysis
solution (dialysate bath) (synethetic membrane)

Peritoneal Peritoneal membrane is the semi

permeable membrane
 Osmosis-Diffusion-Ultrafiltration

Osmosis - movement fluid from an area of < to >

concentration of solutes (particles)

Diffusion - movement of solutes (particles) from an area of

> concentration to area of < concentration [Remove urea,
creatinine, uric acid and electrolytes, from the blood to the
dialystate bath] RBC, WBC, Large plasma proteins do not go
through

Ultrafiltration Water and fluid removed when the

pressure gradient across the membrane is created, by
increase pressure in the blood compartment & decrease
pressure in the dialysate compartment
Peritoneal dialisis
 Hemodialysis

Vascular access for high blood flow

Shunts, (telfon, external)
Arteriovenous fistulas and grafts (AV)
Anastomosis between an artery and vein
Fistulas are native vessels (4-6 wks
maturity)
Grafts are artificial/synthetic material
Dializer= pengganti ginjal
AV fistula communication

AV Graft access
Hemodialisis
PD Advantages PD disadvantages

Immediate initiation Bacterial/chemical periotonitis

Less complicated Protein loss
Portable (CAPD) Exit site of catheter
Fewer dietary restrictions Self image
Hyperglycemia
Short training time
Surgical placement of catheter
Less cardio stress
Multiple abdominal surgery
Choice for diabetics
 Nursing Care Pre, Post Dialysis

Weigh before & after

Assess site before & after (bruit, thrill, infection,

bleeding etc.)

Medications (precautions before & after)

Vital signs before and after etc.

 Renal transplant
Living and Cadaveric donors
Predialysis: obtain a dry weight free of excess fluids and
toxins
More preparation time from a living donor vs. cadaveric
transplant within 36 hours of procurement
Delay may increase ATN
Pre-transplant: Immunotherapy (IV methylprednisolone
sodium succinate, (A methaPred, Solu-
Medrol), cyclosporine (Sandimmune and azathioprine
((Imuran)
 Complications Post Transplant

Rejection is a major problem

Hyperacute rejection: occurs within minutes to

hours after transplantation

Renal vessels thrombosis occurs and the kidney

dies

There is no treatment and the transplanted

kidney is removed
 Chronic Rejection: occurs over months or years
and is irreversible.
The kidney is infiltrated with large numbers of T
and B cells characteristic of an ongoing , low
grade immunological mediated injury
Gradual occlusion renal blood vessels
Signs: proteinuria, HTN, increase serum
creatinine levels
Supportive treatment, difficult to manage
Replace on transplant list
References:

Black, JM. & Matassarin-Jacobs, E. (1997). Medical surgical nursing: Clinical

management for continuity of care. (5th ed.).WB Saunders Company,
Philadelphia.
Goldman, L. & Bennett, JC. (2001). Pocket companion to cecil textbook of
medicine (21st ed.). WB Saunders Company, Philadelphia.
Reeves, CJ., Roux, G., Lochart, R. (2001). Keperawatan medikal bedah (Ed.
Setyono, J.). Penerbit Salemba Medika, Jakarta.
Sukandar, E. (1997). Nefrologi klinik. (2nd ed.). Penerbit ITB, Bandung.
Wilson, DD. (1998). Nurses guide to understanding laboratory and diagnostic
test. Lippincott William&Wilkins, Philadelphia.
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