SALURAN PENCERNAAN

Pendahuluan
KEPERAWATAN PERIOPERATIF: Istilah yang digunakan untuk menggambarkan fungsi keperawatan yang berkaitan dengan pengalaman pembedahan pasien.

PERIOPERATIF Suatu istilah gabungan yang mencakup tiga fase pengalaman pembedahan: praoperatif intraoperatif, dan pascaoperatif.

PERIOPERATIVE NURSING
tujuan :

1. Menberikan pelayana yang aman,

suportif, dan komprehensif 2. Membantu the surgeon dengan berfungsi sebagai anggota tim yang efektif 3. Menciptakan dan mempertahankan lingkungan yang aseptic / sterile

1. FASE PRAOPERATIF Dimulai ketika keputusan untuk intervensi

bedah dibuat dan berakhir ketika pasien dikirim ke meja operasi.

Lingkup aktifitas keperawatan: pengkajian dasar pasien di tatanan klinik atau di rumah wawancara praoperatif menyiapkan pasien untuk anestesi pada pembedahan.

2. FASE INTRA OPERATIF Dimulai ketika pasien masuk ke ruang operasi (meja operasi) dan berakhir saat pasien dipindahkan ke ruang pemulihan (RR/PACU).

Lingkup aktifitas keperawatan: memasang infus memberikan medikasi intravena melakukan pemantauan fisiologis menyeluruh sepanjang prosedur pembedahan menjaga keselamatan pasien.

3. FASE PASCAOPERATIF Dimulai pada saat pasien masuk ke ruang pemulihan dan berakhir dengan evaluasi tindak lanjut pada tatanan klinik atau di rumah.
Lingkup aktifitas keperawatan: Mengkaji efek agen anestesi membantu fungsi vital tubuh, serta mencegah komplikasi. Peningkatan penyembuhan pasien dan penyuluhan, perawatan tindak lanjut, rujukan yang penting untuk penyembuhan yang berhasil dan rehabilitasi diikuti dengan pemulangan.

Klasifikasi pembedahan (1)

1. Berdasarkan tingkat resiko/keseriusan

Mayor : melibatkan banyak bagian tubuh, beresiko besar terhadap keselamatan jiwa

Ex: : Open heart surgery , Removal of a kidney

Minor : melibatkan sebagian kecil anggota tubuh, biasanya bertujuan untuk memperbaiki perubahan bentuk,resiko lebih rendah dibandingkan prosedur mayor Ex: operasi katarak

Klasifikasi pembedahan (2)

2. Berdasarkan tingkat urgensinya (kedaruratannya)
a. KEDARURATAN: Pasien membutuhkan perhatian segera; ganguan

mungkin mengancam jiwa. Indikasi untuk pembedahan: Tanpa ditunda. Contoh: Perdarahan hebat, obstruksi kandung kemih atau usus, fraktur tulang tengkorak, luka tembak atau luka tusuk, luka bakar sangat luas.
Indikasi u/ pembedahan: Dalam 24-30 jam. Contoh: Batu ginjal atau batu pada ureter.

b. URGEN: Pasien membutuhkan perhatian segera. c. DIPERLUKAN: Pasien harus menjalani pembedahan

Indikasi u/ pembedahan: Direncakan dalam beberapa minggu/ bulan. Contoh: Hiperplasia prostat tanpa obstruksi kandung kemih, gangguan tiroid, katarak. Indikasi u/ pembedahan: Tidak dilakukan pembedahan jika tidak terlalu membahayakan. Contoh: Perbaikan eskar, Perbaikan vaginal, Hernia sederhana PILIHAN: Keputusan terletak pada pasien. Indikasi u/ pembedahan: Pilihan pribadi. Contoh: Bedah kosmetik.

d. ELEKTIF: Pasien harus dioperasi ketika diperlukan.

a.

Klasifikasi pembedahan (3)

2. Berdasarkan tingkat indikasi/tujuan pembedahan Diagnostic-Allows to confirm diagnosis (biopsi, laparatomi eksplorasi) Corrective/kuratif: Excision or removal of diseased body part (Eksisi tumor, apendiktomi) Reconstructive-Restore function or appearance to traumatized or malfunctioning tissues (ORIF, scar revision) Procurement for transplant- Removal of organs and/or tissues from a person pronounced brain death for transplantation into another person. Constructive- Restores function lost or reduced as result of congenital anomalies. (cleft palate repair, closure of septal defect) Cosmetic- Performed to improve personal appearance *mammoplasti) PALIATIF: Untuk menghilangkan nyeri atau memperbaiki masalah (pemasangan selang gastrostomi, debridement of necrotic tissue)

ASA (American Society of Anesthesiologists) Classification

P1 = A normal healthy client P2 = A client with a mild systemic disease (CV disease

with minimal limitations) P3 = A client with a severe systemic disease (DM, HTN, Obesity) P4 = A client with a severe systemic disease that is a constant threat to life P5 = A moribund client who is not expected to survive without the operation A client declared brain dead whose organs are being removed for donor purpose

Perawatan pre operatif Assessment

Assessment in the pre-admission unit, client room, holding area or induction room Nursing History identifikasi kebutuhan dan resiko klien terhadap operasi Medical History
History of past illnesses and surgeries Alasan utama masuk rumah sakit Pre-existing illnesses can influence ability to tolerate

and recover from surgery Medication History- any medications that might predispose to surgical complications.

Allergies- medications, topical agents used to prepare the skin for surgery, dan latex Smoking Habits greater risks for complications Greater risk of post-op pulmonary complications Alcohol and Controlled Substance Use and abuse
Menimbulkan efek merugikan dari anesthetic agents Dapat menyebabkan kelaianan perdarahan (bleeding

disorders (potentially) withdrawal

Client Expectations- to identify the clients and family perceptions and expectations regarding surgery and health care providers.

Family Support- determine the extent of the clients support from family members or friends. Occupation- surgery may result in physical alterations that hinder or prevent a person from returning from work. Feeling- surgery menyebabkan ansietas dan kehilangan kontrol emosi bagi kebanyakan pasien Cultural and Spiritual Factors- cultural differences in the use of both verbal and nonverbal communication require you to validate interpretation of cues with the client and family. Coping Resources- assessment of a clients feeling and self-concept helps to reveal whether the client has the ability to cope with the stress of surgery. Body image-surgical removal of a diseased tissue often leaves permanent disfigurement or alteration in body function.

1. Persiapan psikologis emosi pasien & keluarga labil o/k takut/cemas dan faktor sosial ekonomi diperlukan dukungan emosional dan penyuluhan/KIE: Pemeriksaan-pemeriksaan sebelum operasi (alasan persiapan). - Hal-hal yang rutin sebelum operasi. - Alat-alat khusus yang diperlukan - Pengiriman ke ruang bedah. - Ruang pemulihan. Orientasi

Risk Factors
Age Very young and old at risk due to anesthetics causing vasodilation and heat loss Potential for decreased blood volume Very old less able to adapt to the stress of surgery Nutrition Malnutrisi berpengaruh terhadap anesthesia, infection, poor wound healing and the potential for multiple organ failure after surgery. Requires at least 1500kcal/day to maintain energy reserves Increased protein, vitamins A and C, and zinc facilitate wound healing Obesity Reduced ventilation and cardiac function Beresiko lebih tinggi terjadinya Embolus, atelectasis and pneumonia post-op

 Fluid and Electrolyte Imbalance Negative nitrogen balance and elevated glucose can delay healing Adrenocortical stress response water and sodium retained and K+ lost 2-5 days post-op Pregnancy Pembedahan dilakukan hanya pada kondisi yang benar2 emergensi/urgen

Perioperative Nursing Care

Physical assessment/clinical manifestations

General survey- gestures and body movements may reflect decreased energy or weakness caused by illness. Cardiovascular system- gangguan jantung menyebabkan 30% kematian perioperatif Respiratory system-penurunan fungsi pernapasan mengindikasikan resiko terjadinya komplikasi pernapasan pasca dan intra operasi

Perioperative Nursing Care

Physical assessment/clinical manifestations

Renal system- fungsi abnormal renal menggangu

keseimbangan cairan dan elektrolit serta menurunkan kemampuen tubuh untuk membuang obat2an dan agen anastesi Neurologic system- a clients LOC will change as a result of general anesthesia but should return to the preoperative LOC after surgery.

Perioperative Nursing Care

Physical assessment/clinical manifestations

Musculoskeletal system- Deformities may interfere with intraoperative and postoperative positioning. Avoid positioning over an area where the the skin shows signs of pressure over bony prominences.
Gastrointestinal system- alteration in function after surgery may result in decreased or absent bowel sound and distention.

Head and Neck- the condition of oral mucous membranes reveals the level of hydration.

Perioperative Nursing Care

Gerontological Considerations
CardiovascularCoronary flow decreasesHeart rate

decreasesResponse to stress decreasesPeripheral vascular decreasesCardiac output decreases Cardiac reserve decreases

Perioperative Nursing Care

Gerontological Considerations
Respiratory SystemStatic lung volumes decreases

Pulmonary static recoil decreasesSensitivity of the airway receptors decreases Nervous systemIncreased incidence of post.op. confusionIncreased incidence of deliriumIncreased sensitivity to anesthetic agents

Perioperative Nursing Care

Gerontological Considerations
Renal SystemRenal blood flow declines 1.5% per

yearRenal clearance reduced GastrointestinalDecreased intestinal motility Decreased liver blood flowDelayed gastric emptying

Perioperative Nursing Care

Gerontological Considerations
MusculoskeletalDecreased mass, tone, strength

Decreased bone density IntegumentaryDecreased elasticityDecreased lean body massDecreased subcutaneous fat

Perioperative Nursing Care

Laboratory and diagnostic studies
Screening tests depend on the condition of the client

and the nature of the surgery. If test reveals severe problems the surgery may be cancel until the condition is stabilized.Blood type and screen, urinalysis, 12 lead EKG and chest X-ray are ordered to screen for pre-existing abnormalities.

Nursing Diagnosis
Ineffective airway clearance Anxiety Fear Risk for deficient fluid volume Risk for perioperative-positioning injury Deficient knowledge Impaired physical mobility Nausea Acute pain Delayed surgical recovery

Post-Operative Exercises
Diaphragmatic breathing= pernapasan diafragma
Incentive spirometry Turning, coughing, deep breathing Leg exercises Elastic stockings (TED hose and/or SCDs) Teach pre-op and have patient do return

demonstration to ensure understanding Pain management

Diaphragmatic Breathing and Splinting When Coughing

Leg Exercises and Foot Exercises

Physical Preparation Maintenance of normal fluid and electrolyte balance

NPO (nil per os) = puasa

6 hours after light meal 4 hours for breast milk Clear liquids 2-3 hours

8 jam menjelang operasi pasien tidak diperbolehkan makan, 4 jam

sebelum operasi pasien tidak diperbolehkan minum, (puasa) pada operasi dengan anaesthesi umum. Pada pasien dengan anaesthesi lokal atau spinal anaesthesi makanan ringan diperbolehkan.
Aspirasi!!!!

Reduction of risk of surgical wound infection Pre-op antibiotics Skin prep Shaving

 Prevention of bowel and bladder incontinence Bowel prep Enemas till clear

Pemberian lavement sebelum operasi dilakukan pada bedah saluran pencernaan atau pelvis daerah periferal. Untuk pembedahan pada saluran pencernaan dilakukan 2 kali yaitu pada waktu sore dan pagi hari menjelang operasi. Maksud dari pemberian lavement antara lain : - Mencegah cidera kolon - Memungkinkan visualisasi yang lebih baik pada daerah yang akan dioperasi. - Mencegah konstipasi. - Mencegah infeksi.

Promotion of rest and comfort Rest promotes healing Medication may be given night before

Preparation Day of Surgery

Surgical checklist (AHRQ)
Hygiene Oral rinse or brushing of teeth Hair and cosmetics No clips or pins No makeup No glasses/contacts Removal of prosthesis Hearing aides Dentures/partials

Preparation Day of Surgery

Safeguarding valuables Preparing bowel and bladder Enema Urinate Placement of foley catheter Vital signs Documentation Performing special procedures IV, NG (most often done in OR) Administer pre-op medications

Eliminating Wrong Site and Wrong Procedure Surgery

Joint Commission instituted Universal Protocol

guidelines preventing such mishaps Must be implemented whenever an invasive surgical procedure is to be performed no matter the location 3 principles
Preop verification ensuring all documents/studies

available Marking of the operative site Time out just before starting the procedure

Correct client, procedure, site, and any implants All members of team must participate

Transport to the OR

Usually done by an orderly Verify pt. with ID bracelet and chart to ensure correct pt. is

being transported (pt. may be drowsy from pre-meds) Provide family an opportunity to visit prior to transport Direct family to waiting area 30-60 menit sebelum operasi dimulai Prepare the bed and room for the clients room
VS equipment Emesis basin Clean gown Washcloth, towel and facial tissues IV pole Suction equipment (if needed) O2 equipment Extra pillows and chux pads on bed

Perioperative Nursing Care Medications

Sedatives/hypnotics- Nembutal
Tranquilizers-Ativan, versed, valium Opiate analgesics- Demerol, morphine Anticholinergics-Atropine sulfate,atarax H2o blockers.- Tagamet, Zantac Antiemetic- Reglan, Phenergan

Informed Consent
Surgeons responsibility Placed in med record to go to OR with client

 LEGAL PREPARATION: Surgeon obtains operative permit (informed

consent) menjelaskan ttg: 1. Prosedur operasi, alternative, kemungkinan komplikasi. 2. Peran perawat advocate bagi klien confirm that the client understands information given.

 INFORMED CONSENT diperlukan untuk:

Invasive procedures, such as surgical incisions,

biopsy, cystoscopy or paracentesis. Procedures yang memerlukan sedasi atau anesthesia A non-surgical procedure, such as arteriography Procedures radiasi (zat radioaktif)

Yang berhak mendatangani IC

Adult client (over 18 y/o) signs own permit unless

unconcious or mentally incompetent. 1. If unable to sign, relative (spouse or next of kin) or guardian will sign. 2. In an emergency bisa lewat telp, tapi harus ada pendengar kedua di telp (sekaligus sebagai saksi)

Consents are not needed for emergency care jika keempat kriteria berikut ini terpenuhi:
a. Sangat /segera mengancam jiwa
b. Experts/dokter ahli sepakat bahwa keadaanx

emergency c. Client tidak mampu memberikan persetujuan. d. Orang2/klg yang syah secara hukum untuk memberikan persetuuan tidak bisa dihubungi

Terima kasih