ASUHAN KEPERAWATAN PADA KLIEN TN.

J DENGAN
BATU GINJAL DI PAVILIUN ERI SOEDEWO
RSPAD GATOT SOEBROTO

Disusun oleh Kelompok 8

Anisa Aulia Defani

Ega Purwantiningsih
Dewa Adi Wiradhika
Chesea Dwi Cahyani
Erine Amalya
Mariska Indah
Menpedrianto
Nur Rizki Ayunda
Riafi Mahligai
Siti hazar Hasanah
Tri Mutiasasri
APA ITU BATU GINJAL?
Adalah Batu yang ada ginjalnya X
Latar Belakang

Batu ginjal adalah suatu keadaan terdapat satu atau lebih batu di dalam pelvis
1 atau calyces ginjal atau di saluran kemih (Pratomo, 2007). Proses
pembentukan batu ini disebut urolitiasis (litiasis renalis, nefrolitialis).

Batu di dalam kandung kemih bisa menyebabkan nyeri di perut bagian bawah.
Batu yang menyumbat ureter, pelvis renalis maupun tubulus renalis bisa
menyebabkan nyeri punggung atau kolik renalis (nyeri kolik yang hebat). Kolik
renalis
ditandai dengan nyeri hebat yang hilang-timbul, biasanya di daerah antara
tulang rusuk dan tulang pinggang, yang menjalar ke perut, daerah kemaluan
dan paha sebelah dalam.
Penyebab

1) Faktor intrinsic

• Hereditair (keturunan).
• Umur penyakit batu saluran kemih paling sering didapatkan pada usia 30 - 50
tahun
• Jenis kelamin jumlah pasien laki-laki tiga kali lebih banyak disbanding dengan
pasien perempuan

2) Faktor ekstrinsiknya

• Asupan air kurangnya asupan air dan tingginya kadar mineral kalsium pada air
yang dikonsumsi, dapat meningkatkan insiden batu saluran kemih.
• Diet obat sitostatik untuk penderita kanker juga memudahkan terbentuknya batu
saluran kemih, karena obat sitostatik bersifat meningkatkan asam urat dalam tubuh
• Iklim dan temperatur individu yang menetap di daerah beriklim panas dengan
paparan sinar ultraviolet tinggi akan cenderung mengalami dehidrasi
• Pekerjaan penyakit ini sering dijumpai pada orang yang pekerjaanya banyak
duduk
 Menifestasi Klinis
01
Infeksi (pielonefritis dan sistitis yang disertai menggigil, demam, dan disuria) dapat terjadi dari iritasi
batu yang terus menerus.

02
Beberapa batu, jika ada, menyebabkan sedikit gejala umum secara perlahan merusak unit fungsional
(nefron) ginjal: sedangkan yang lain menyebabkan nyeri yang luar biasa dan ketidak nyamanan

Batu yang terjebak di ureter menyebabkan gelombang nyeri yang luar biasa, akut, dan kolik yang

03 menyebar ke paha dan genitalia. Pasien merasa ingin berkemih, namun hanya sedikit urin yang
keluar, dan biasanya mengandung darah akibat aksi abrasif batu.

Batu yang terjebak di kandung kemih biasanya menyebabkan gejala iritasi dan berhubungan dengan
04 infeksi traktus urinarius dan hematuria.
ASUHAN KEPERAWATAN BATU GINJAL MENURUT TEORI
1. Perubahan eliminasi urine berhubungan
dengan obstruksi bedah, tekanan dan mitasi
kateter/ badan
Tujuan : Perubahan eliminasi urine dapat teratasi
dengan kriteria hasil kandung kemih
kosong secara penuh, tidak ada residu urin > 100-200cc,
bebas dari ISK, tidak ada spasme
bladder, balance cairan seimbang.
Intervensi :
1. Monitor intake dan output
2. Instruksikan pada keluarga pasien untuk memonitor
output urin
3. Kateterisasi jika perlu
2. Resiko tinggi terhadap kekurangan volume cairan
berhubungan dengan kesulitan mengontrol perdarahan,
pembatasan pra- operasi
Tujuan : resiko tinggi terhadap kekurangan volume
cairan tidak terjadi dengan kriteria hasil tekanan darah
dalam
rentang normal, Integritas kulit baik.
Intervensi :
1. Monitor tanda-tanda vital klien
2. Pasang kateter urin sesuai indikasi
3. Beri terapi cairan sesuai indikasi
3. Resiko tinggi terhadap infeksi berhubungan dengan
trauma jaringan sekunder terhadap: presedur bedah,
presedur alat invasive, alat selama pembedahan kateter,
irigasi kandung kemih.
Tujuan : resiko infeksi tidak terjadi
dengan kriteria hasil tanda-tanda vital dalam keadaan
normal, pasien bebas dari tanda dan gejala infeksi, jumlah
leukosit dalam batas normal.
Intervensi :
1. Monitor tanda dan gejala infeksi
2. Dorong masukan nutrisi yang cukup
3. Pertahankan teknik aseptik
4. Nyeri berhubungan dengan iritasi mukosa kandung
kemih, reflek spasme otot: presedur bedah atau
tekanan dari balon kandung kemih.
Tujua : nyeri teratasi dengan kriteria hasil pasien
mampu mengontrol nyeri, mampu mengenali nyeri.
Intervensi :
1. Lakukan pengkajian nyeri secara komprehensif
2. Ajarkan tentang teknik non farmakologi seperti
teknik relaksasi nafas dalam
3. Kolaborasi dalam pemberian antispasmodic
TINJAUAN KASUS
A. PENGKAJIAN
Pengkajian dilakukan pada tanggal 17 Juli 2021 di Ruang Paviliun
Kartika 3 RSPAD Gatot Soebroto klien masuk pada tanggal 15 Juli
2021
dengan nomor register 01009007 dan dengan diagnosa Batu Ginjal.

1. Identitas Klien
Klien bernama Tn. S, jenis kelamin laki-laki, usia 57 tahun, status
perkawinan menikah, agama Islam, suku Jawa, pendidikan SMP,
bahasa yang digunakan bahasa Indonesia, pekerjaan PNS, Alamat
JlHuni Malaka RT. 004, RW 006, Hunjul, Cipayung. Sumber biaya
BPJS Dinas kelas II, sumber informasi dari pasien .

2. Resume
Klien masuk rumah sakit melalui poli bedah kamis 15 Juli 2021 jam
11:22 WIB klien mengatakan nyeri pinggang sebelah kanan. klien
mengatakan pipis berwarna putih susu.
Data penunjang (Pemeriksaan diagnostik: Laboratorium, Radiologi dan lain-lain)
Hasil Lab 16-07-2021
a. Hemoglobin : 10.5 g/dL (13.0 – 18.0 g/dl )
b. Hematokrit : 30 % (40 – 52 % )
c. Eritrosit : 4.1 juta/‫ע‬L (4.3 – 6.0 juta/ ‫ע‬L )
d. CREAT : 9 mg/dL (0.80 – 1.30 mg/dL)
e. Urea : 17 mg/dL (15-43 mg/dL )

Penatalaksanaan ( Therapi/pengobatan termasuk diet)

 - Infuse sodium chlorium20 tetes/ menit

 cefoperazon 2x1 mg

 ondancentron 2x1 mg

 lasix 2x1 mg
ANALISA DATA

Nyeri akut berhubungan dengan agen Resiko tinggi terhadap infeksi berhubungan
pecedera fisik dengan Insisi bedah / adanya luka bekas operasi

Ds.
-Klien mengatakan nyeri pingang sebelah kanan DS:
bekas operasi. -Klien mengatakan lukanya bernanah dan
-Klien mengatakan nyeri yang dirasakan seperti berdarah.
menusuk-nusuk
DO:
Do. -Terdapat ada balutan luka di pinggang
-Klien tampak terpasang slang dipinggang sebelah kanan
sebelah kanan. -Luka klien ±2 cm.
-Klien tampak meringis -TD : 135/80 mmHg
-Klien tampang memegang pinggang sebelah HR : 85 kali/menit RR : 20 kali/menit
kanan Suhu : 37 0C
-Klien terlihat gelisah
-Skala nyeri 4
-TD : 135/80 mmHg
HR : 85 kali/menit
RR : 20 kali/menit
Suhu : 37 0C
Defisit perawatan diri mandi berhubungan
dengan Kelemahan dan kelelahan

DS:
-Klien mengatakan sudah 3 hari belum mandi.
-Klien mengatakan badanya berkeringat dan
lengket.
-Klien mengatakan tidak nyaman
-Wajah klien tampak kusam

DO :
- Kulit klien tampak berdaki dan kotor
- Badan klien berbau
- Terpasang slang di pinggang sebelah kanan
pasien
- Terpasang infuse ditangan sebelah kanan
- Klien terpasang kateter
 Intervensi Keperawatan
1. Nyeri akut b.d agen pencedera
fisik
Tujuan: nyeri klien
berkurang
Kriteria hasil : Skala nyeri 0-1,
Klien mengatakan nyeri
berkurangKlien nyaman dan
tenang.
Intervensi :
1) Kaji skala nyeri
2) Ajarkan teknik relaksasi napas
dalam
3) Beri obat analgeik sesuai
program.
2. Resiko infeksi b.d insisi
bedah/adanya luka bekas
operasi
Tujuan: Resiko infeksi tidak
terjadi
Kriteria hasil : paisen
bebas dari tanda dan gejala
infeksi, TTV dalam batas
normal Intervensi :
1) Monitor tanda-tanda vital.
2) Kaji keadaan luka.
3) Lakukan perawatan luka.
3. Defisit perawatan diri b.d
kelemahan dan kelelahan
Tujuan : klien bisa melakukan
perawatan diri mandi
Kriteria Hasil: Klien mengatakan
rasa nyaman dan segar setelah
mandi
Intervensi:
1) Kaji kemampuan klien untuk
perawatan diri yang mandiri.
2) Dukung keluarga untuk
berpartisipasi dalam membantu
aktivitas klien
3) Lakukan personal hygiene.
PENATALAKSANAAN
Dx 1: Nyeri akut b.d agen pencedera Fisik
Tanggal 17 Juli 2021
Pukul 09.00 mengkaji nyeri, hasil: S: skala 3, nyeri sedang. Pukul 11.00 Mengajarkan klien teknik relaksasi napas dalam,
hasil : Klien mengikuti instruksi dan merasa nyaman. Pukul 12.00 memberikan obat Analgetik 3x1, hasil : obat masuk
dengan lancar. Pukul 18.00 memberikan obat analgetik, hasil : obat masuk dengan lancar.

Tanggal 18 Juli 2021

Pukul 07.00 memberikan obat analgetik 3x1, hasil : obat masuk dengan lancar. Pukul 09.00 mengkaji nyeri, hasil: S: skala
2, nyeri sedang. Pukul 11.00 Mengajarkan klien teknik relaksasi napas dalam, hasil : Klien mengikuti instruksi dan merasa
nyaman. Pukul 12.00 memberikan obat Analgetik 3x1, hasil : obat masuk dengan lancar. Pukul 18.00 memberikan obat
analgetik, hasil : obat masuk dengan lancar.

Tanggal 19 Juli 2021

Pukul 07.00 memberikan obat analgetik 3x1, hasil : obat masuk dengan lancar. Pukul 09.00 mengkaji nyeri, hasil: S: skala
1, nyeri sedang. Pukul 11.00 Mengajarkan klien teknik relaksasi napas dalam, hasil : Klien mengikuti instruksi dan merasa
nyaman. Pukul 12.00 memberikan obat Analgetik 3x1, hasil : obat masuk dengan lancar. Pukul 18.00 memberikan obat
analgetik, hasil : obat masuk dengan lancar.
PENATALAKSANAAN
DX 2 : Resiko infeksi berhungan dengan Insisi bedah/ adanya luka bekas operasi
Tanggal 17 Juli 2021
Pukul 08.00 Mengkaji TTV, hasil: TD 110/70 mmhg, N 88x/m, S 36c, RR 20x/m. Pukul 10.10 Mengkaji luka, hasil : Luka
klien tampak memerah dan bernanah. Pukul 11.00 Melakukan perawatan luka, hasil : Luka bersih dan perban terganti
rapih. Pukul 14.00 Mengkaji TTV, hasil : TD 120/72 mmhg, N 80x/m, S 37c, RR 18x/m. Pukul 20.00 Mengkaji TTV, hasil :
TD 120/65 mmhg, N 78x/m, S 37c, RR 20x/m.

Tanggal 18 Juli 2021

Pukul 08.00 Mengkaji TTV, hasil: TD 118/70 mmhg, N 85x/m, S 36c, RR 21x/m. Pukul 10.10 Mengkaji luka, hasil : Luka
klien tampak bersih tidak berembes. Pukul 14.00 Mengkaji TTV, hasil : TD 125/75 mmhg, N 83x/m, S 36,2c, RR 18x/m.
Pukul 20.00 Mengkaji TTV, hasil : TD 120/69 mmhg, N 78x/m, S 37c, RR 20x/m.

Tanggal 19 Juli 2021

Pukul 08.00 Mengkaji TTV, hasil: TD 120/72 mmhg, N 80x/m, S 36c, RR 19x/m. Pukul 10.10 Mengkaji luka, hasil : Luka
klien tampak bersih tidak berembes. Pukul 14.00 Mengkaji TTV, hasil : TD 125/75 mmhg, N 85x/m, S 36,1c, RR 18x/m.
Pukul 20.00 Mengkaji TTV, hasil : TD 120/61 mmhg, N 82x/m, S 36,8c, RR 20x/m.
PENATALAKSANAAN
Dx 3: Defisit perawatan diriberhungan dengan kelemahan dan kelelahan
Tanggal 17 Juli 2021
Pada pukul 10.00 Mengkaji kemampuan klien, hasil Klien mandi masih dibantu. Pukul 12.15 Mendukung keluarga untuk
berpaertisipan, hasil : Keluarga membantu dalam melakukan personal hygine klien. Pukul 21.00 Melakukan oral hygine,
Hasil : Gigi klien bersih dan wangi.

Tanggal 18 Juli 2021

Pada pukul 10.00 Mengkaji kemampuan klien, hasil Klien mandi masih dibantu. Pukul 21.00 Melakukan oral hygine, Hasil :
Gigi klien bersih dan wangi.

Tanggal 19 Juli 2021

Pada pukul 10.00 Mengkaji kemampuan klien, hasil Klien mandi masih dibantu. Pukul 21.00 Melakukan oral hygine, Hasil :
Gigi klien bersih dan wangi.
THANKS
 EVALUASI

1: Nyeri akut b.d agen pencedera Fisik 2. Resiko infeksi berhungan dengan Insisi
bedah / adanya luka bekas operasi
Evaluasi 20 Juli 2021
Evaluasi 20 Juli 2021
S: pasien mengatakan bahwa nyeri berkurang
S: Klien mengatakan sudah BAB
O: Skala nyeri 1
O: Perban tampak bersih dan tidak berembes
A: masalah teratasi, tujuan tercapai
A: masalah teratasi, tujuan tercapai
P: Intervensi dihentikan
P: Intervensi dihentikan

3. Defisit perawatan
diriberhungan dengan kelemahan
dan kelelahan
Evaluasi 20 Juli 2021
S: pasien mengatakan aktivitas masih dibantu
O: Pasien tampak bersih
A: masalah brlum teratasi, tujuan belum tercapai
P: intervensi dilanjutkan (Kaji kemampuan mandiri klien)
TINJAUAN TEORI

Urolitiasis mengacu pada adanya batu (kalkuli) ditraktus

urinarius. Batu terbentuk di dalam traktus ketika konsentrsi
substansi tertentu seperti kalsium oksalat, kalsium fospat, dan
asam urat meningkat. Batu juga dapat terbentuk ketika terdapat
defisiensi substansi tertentu, seperti sitrat yang secara normal
mencegah
kristalisasi dalam urine.
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Easy to change colors, photos and Text. Get a modern PowerPoint Presentation that is
beautifully designed. I hope and I believe that this Template will your Time, Money and
Reputation. Easy to change colors, photos and Text. I hope and I believe that this
Template will your Time, Money and Reputation.

Get a modern PowerPoint Presentation that is beautifully designed. I hope and I believe
that this Template will your Time, Money and Reputation.

Easy to change colors, photos and Text. Get a modern PowerPoint Presentation that is
beautifully designed. I hope and I believe that this Template will your Time, Money and
Reputation. Easy to change colors, photos and Text. I hope and I believe that this
Template will your Time, Money and Reputation. Easy to change colors, photos and Text.
Get a modern PowerPoint Presentation that is beautifully designed. I hope and I believe
that this Template will your Time, Money and Reputation.
 Columns Style
Insert the title of your subtitle Here
Easy to change colors, photos and
Text. Get a modern PowerPoint
Presentation that is beautifully
designed. I hope and I believe that this
Template will your Time, Money and
Reputation. Easy to change colors,
photos and Text. I hope and I believe
that this Template will your Time,
Money and Reputation.
Get a modern PowerPoint
Presentation that is beautifully
designed. I hope and I believe that this
Template will your Time, Money and
Reputation.
Easy to change colors, photos and
Text. Get a modern PowerPoint
Presentation that is beautifully
designed. I hope and I believe that this
Template will your Time, Money and
Reputation. Easy to change colors,
photos and Text. I hope and I believe
that this Template will your Time,
Money and Reputation.
Get a modern PowerPoint
Presentation that is beautifully
designed. I hope and I believe that this
Template will your Time, Money and
Reputation.
Thank you
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your subtitle Here
 Fully Editable Icon Sets : A

You can Resize without

losing quality

You can Change Fill Color &

Line Color

FREE
PPT
TEMPLATES
www.allppt.com
 Fully Editable Icon Sets : B

You can Resize without

losing quality

You can Change Fill Color &

Line Color

FREE
PPT
TEMPLATES
www.allppt.com
 Fully Editable Icon Sets : C

You can Resize without

losing quality

You can Change Fill Color &

Line Color

FREE
PPT
TEMPLATES
www.allppt.com