Asuhan Keperawatan Medikal Bedah

Dengan Gangguan Sistem Gastrointestinal

“KOLELITIASIS”
 KOLELITIAS
IS
KANTUNG BATU
EMPEDU

Batu dalam KANTUNG EMPEDU

 KOLELITIASI
sebagai pS
enyakit BATU EMPEDU
merupakan penyakit ya
ng terdapat batu
di dalam kandung emp
edu atau di dalam
saluran kandung em
pedu yang pada
umumnya komposisi
utamnya adalah
kolesterol
 Pathology Empedu
KOLESTEROL

GARAM
EMPEDU

LESITIN

INTI SELUBUNG
HIDROFOBIK HIDROFILIK

BILIRUBIN
 KOLESTEROL

GARAM
EMPEDU
MISEL

LESITIN

INTI SELUBUNG
HIDROFOBIK HIDROFILIK

BILIRUBIN
PATHWAY
 Mengkonsuumsi makanan lemak
berlebih
ULTRASI
SPASME
Kadar Kolesterol
Di dalam EMPEDU Luka karna gesekan antara
batu empedu dengan
NYERI KHOLIK dinding seluran empedu
Garam Empedu & Lesitin

Merasngsang sel sel epitel

di dalam
Kolesterol keluar dari MISEL Peradangan
Duo Denum
(Hormon CCK) SALURAN EMPEDU

KRISTAL EMPEDU (OBSTRUKSI)

VASOKENTRIKSI
Dari Kantung Empedu Batu Empedu (KOLELITIASIS)

Manifestasi JAUDICE
(Kekuningan)
Kantung Empedu

KONTRIKSI
(Terdorong)

Gangguan Epigastrik Rasa Nyeri MUAL dan Muntah MK : NAUCEA

MK : Resiko Defisit Nutri

MK : Nyeri Akut
 Asuhan
Keperawatan
PENGKAJIAN
IDENTITAS PASIEN
Nama : Tn. H

Umur : 55 Tahun

Jenis Kelamin : Laki – laki

Status : Sudah Menikah

Agama : Kristen

Pendidikan : SMA

Pekerjaan : Wiraswasta

Alamat : Komp. Batu Ceper Permai

Blok. Q13, Kota Tangerang

 Data Medik

1 Diagnosa Medis
Saat Masuk : Gastritis
Saat Pengkajian : Kolelitiasis
2 Alasan Masuk Rumah Sakit : Pasien mengatakan sakit pada Ulu Hati, Pasien
mengira mengalami Sakit Jantung, dan merasakan
mual muntah
3 Keluhan Utama Saat Pengkajian : Dalam pengkajian yang di lakukan, Tn. H
mengatakan Nyeri Ulu Hati yang menjalar dan terasa
sampai kebagian pungung (seperti di remas), Mual
Muntah (+)
4 Riwayat Kesehatan saat ini
(PQRST)
P (paliatif) : Pasien mengatkan timbul nyeri saat beraktivitas
: Nyeri terasa seperti tertusuk tusuk (frekuensi Nyeri
Q (quality)
hilang timbul)
R (region) : Lokasi Nyeri Ulu Hati, menjalar ke seluruh tubuh

S (skala) : Sedang (skala 4)

T (timing) : Terasa sejak sore hari, (terjadi secara bertahap)

 Keterangan Sebelum sakit Saat sakit

Frekuensi 3 x sehari 1-2 x sehari

Jenis Normal Injeksi infus ( IV) : Smof

kabiven peripheral 1448
ml

Porsi Porsi penuh 3 x 1 hari Pasien hanya makan 1/5

porsi -1 porsi, 1-2 kali
sehari

Total konsumsi 3x1 1 -2 x sehari

Keluhan/pantangan Tidak ada Menghindari makan

berlemak lebih
 Pemeriksaan fisik
PEMERIKSAAN FISIK UMUM

• Berat badan :60 kg

• Tinggi badan :161 cm
• Tekanan darah :136/85 mmhg
• Nadi :83 x/menit
• Frekuensi nafas :20 x/menit
• Suhu tubuh :36,6 derajat Celsius
• Keadaan umum : kurang baik
• Kesadaran : compos mentis
 PEMERIKSAAN RCP
(27 mei 2021)

Hemotologi rutin
4,8 (5,00-10,00) Bilirubin Total- Dir – 1.57<1.0
Leukosit (L)
4,8 (4,5-5,5)G/DL Indirek 0.91<0.3
Eritrosit
13,4 (13-17) Bilirubin total (H) 0.66<0.8
Hemoglobin
42 %(40-50) Bilirubin direk (H)
Hematokrit
254 (150-400) Bilirubin indirek
Trombosit
64 (25-115)
Kimia Klinik Profil pancreas 406 (73-393)
194 (<36) Amilase total
Profil hati (H)
Lipase(H)
194 <36
AST (SGOT )(H)
219 <50
ALT(SGPT)(H)
701 <61
Gama GT(H)
 ANALISA DATA

TANGGAL PENGELOLAHAN DATA ETIOLOGI MASALAH

24-05-2021 Pre Operatif

Agen pencedera Fisiologis
Ds:
-Pasien mengatakan nyeri di ulu hati(epi tampak sulit tidur,gelisah
gastriks)
-Pasien mengatakan nyeri skala nyeri 4
-Pasien mengatakan nyeri tertusuk-tusuk,
menjalar hingga ke keseluruh tubuh
Do:
-Pasien tampak Pucat, Meringis
-Pasien sulit tidur
TTV
• TD:Tekanan darah :136/85 mmhg
• Nadi :83 x/menit
• Frekuensi nafas :20 x/menit
• Suhu tubuh :36,6CREDITS:
derajat Celsius
This presentation template was created by
Slidesgo, including icon by Flaticon, and infographics &
images from Freepik
 ANALISA DATA

TANGGAL PENGELOLAHAN DATA ETIOLOGI MASALAH

24-05-2021 Pre operatif Gangguan Pankreas

Ds:
-Pasien mengatakan Mual
-Pasien merasa ingin muntah setiap kali
makan
-pasien enggan makan
Do:
-pasien tampak lemas
-pasien tampak pucat
-pasien terlihat muntah
-TTV:
• TD:Tekanan darah :136/85 mmhg
• Nadi :83 x/menit
• Frekuensi nafas :20CREDITS:
x/menit This presentation template was created by
Slidesgo, including icon by Flaticon, and infographics &
• Suhu tubuh :36,6 derajat Celsius
images from Freepik
 ANALISA DATA

TANGGA PENGELOLAHAN DATA ETIOLOGI MASALAH

L
24-05- Pre operatif Ketidakmampuan
2021 Ds: mengabsorpsi
-Pasien mengantakan mual nutrien
-Pasien mengatakan tidak
nafsu makan
Do:
-Pasien tampak pucat
-Pasien tampak ingin muntah
jika makan
• TTV
• TD:Tekanan darah :136/85
mmhg
• Nadi :83 x/menit
• FrekuensiCREDITS:
nafas :20 x/menit
This presentation template was created by
• Suhu tubuh :36,6
Slidesgo, derajat
including icon by Flaticon, and infographics &
Celsius images from Freepik
 ANALISA DATA

TANGGA PENGELOLAHAN DATA ETIOLOGI MASALAH

L
24-05- Pre operatif
2021 Ds:
-Pasien mengatakan Mual
-Pasien merasa ingin muntah
setiap kali makan
-pasien enggan makan
Do:
-pasien tampak lemas
-pasien tampak pucat
-pasien terlihat muntah
-TTV:
• TD:Tekanan darah :136/85
mmhg
• Nadi :83 CREDITS:
x/menit This presentation template was created by
• Frekuensi nafasincluding
Slidesgo, :20 x/menit
icon by Flaticon, and infographics &
• Suhu tubuh :36,6 derajat images from Freepik
Celsius
diagnosa medis
1. nyeri akut berhubungan dengan agen pencedera fisiologis:
informasi ditandai dengan tampak merintih, gelisah ,dan sulit tidur
2. nausea berhubungan dengan gangguan pankreas ditandai dengan
mual muntah
3. resiko defisit nutrisi ditandai dengan ketidakmampuan
mengabsorbsi nutrient
4. kesiapan peningkatan nutrisi ditandai dengan makan teratur dan
adekuat
Tanggal Diagnosis Kriteria hasil Rencana tindakan
keperawatan
24-05-2021 1. nyeri akut setelah dilakukan asuhan keperawatan manajemen nyeri
berhubungan 3 X 24 jam diharapkan keluhan nyeri Observasi :
dengan agen berkurang dengan kriteria hasil: identifikasi lokasi karakteristik
pencedera fisiologis: -keluhan nyeri menurun durasi frekuensi kualitas
informasi ditandai -meringis menurun intensitas nyeri
dengan tampak -gelisah menurun -identifikasi skala nyeri-
merintih, gelisah -kesulitan tidur menurun identifikasi respon nyeri non
,dan sulit tidur -intoleransi terhadap makanan verbal
membaik -identifikasi pengetahuan dan
-mual membaik keyakinan tentang nyeri
-muntah membaik Terapeutik :
-nyeri abdomen membaik -berikan teknik non
-peristaltik usus membaik farmakologis untuk mengurangi
rasa nyeri
-kontrol lingkungan yang
memperberat rasa nyeri
Edukasi :
:-jelaskan penyebab, periode
dan pemicu nyeri-jelaskan
strategi meredakan nyeri
-jelaskan teknik non
farmakologis untuk mengurangi
rasa nyeri
Tanggal Diagnosis Kriteria hasil Rencana
keperawatan tindakan

nausea setelah Observasi:

berhubungan dilakukan -identifikasi
dengan asuhan pengalaman
gangguan keperawatan 3 mual
pankreas X 24 jam -identifikasi
ditandai diharapkan dampak mual
dengan mual keluhan mual terhadap
muntah muntah kualitas hidup
menurun misal nafsu
dengankriteria makan
hasil: Terapeutik:
-keluhan mual -kendalikan
menurun faktor
-perasaan ingin lingkungan
muntah penyebab mual
menurun misalnya: bau
-kemampuan tak sedap-
melakukan kurangi
tindakan untuk hilangkan
mengontrol keadaan
mual muntah penyebab mual
Tanggal Diagnosis Kriteria hasil Rencana
keperawatan tindakan

resiko defisit setelah dilakukan O: memonitor

asuhan keperawatan asupan dan
nutrisi ditandai 3 X 24 jam keluarnya makanan
dengan diharapkan dan cairan serta
ketidakmampua kebutuhan nutrisi kebutuhan kaloriT:
n mengabsorbsi meningkat dengan diskusi perilaku
kriteria hasil: makan dan jumlah
nutrient - porsi makanan aktivitas fisik
yang dihabiskan ( termasuk olahraga
pasien membaik yang sesuai) E:
- -pengetahuan anjurkan membuat
tentang pilihan catatan harian
makanan yang tentang perasaan
sehat membaik dan situasi pemicu
- nyeri abdomen pengeluaran makan
membaik (misalnya muntah)K:
- frekuensi dengan ahli gizi
makanan tentang target berat
membaik badan ,kebutuhan
- nafsu makan kalori, dan pilihan
membaik-asupan makanan
nutrisi membaik
- asupan makanan
membaik
Tanggal Diagnosis Kriteria hasil Rencana
keperawatan tindakan

ansietas setelah dilakukan O: -identifikasi saat

berhubungan asuhan tingkat ansietas
dengan keperawatan 3 X berubah (misalnya
kekhawatiran 24 jam diharapkan kondisi)
mengalami kecemasan T :- ciptakan
kegagalan ditandai berkurang suasana terapeutik
dengan gelisah dengankriteria untuk
sulit tidur merasa hasil: -perilaku menumbuhkan
bingung khawatir gelisah menurun kepercayaan
dengan kondisi -perilaku tegang -motivasi
menurun -pucat mengidentifikasi
menurun -tingkat situasi yang
pengetahuan memicu
meningkat kecemasan
E:-latihan relaksasi
Waktu IMPLENTASI NAMA
PERAWAT
• mengkaji dan mememriksa TTV
• Memonitor pemeriksaan lab
• Mengkaji skala nyeri (apakah sudah turun
atau belum skala nyerinya)
• Mengedukasi pasien agarlebih banyak
istirahat dan memposisikan degan nyaman
• Mengkaji mual muntah pasien
• Memonitor asupan makanan
Waktu Implementasi Nama
perawat
• Menganjurkan posisi duduk
• Menganjurkan pasien menjalani dietnya
• Mengkaji mual muntah
• Mengkaji pola diet yang dijalani
 Concepts and Typology

Type A Type B Type C

Mercury is the Venus is the second Saturn is a gas
closest planet to the planet from the Sun giant and has
Sun several rings
 Symptoms of the Disease

Mars Saturn
It’s a cold place. The Saturn is composed
planet is full of iron mostly of hydrogen
oxide dust and helium

Mercury Venus
Mercury is the Venus is the second
smallest one in the planet from the Sun.
Solar System It’s terribly hot
 Risk Factors
Evolution Prevalence

200,000,000
To modify these graphs, click on them, follow the link, Big Number
change the data and paste the new graphs here
 Key Numbers

6,371 km
Is Earth’s radius

24h 37m 23s 333,000.00

is Jupiter’s rotation period earths is the Sun’s mass
02
Diagnosis
You can enter a subtitle here
if you need it
 Diagnosis

Mercury Jupiter Neptune

Mercury is the Jupiter is the Neptune is the
smallest planet biggest planet farthest planet

Mars Venus Saturn

Mars is a very Venus is the Saturn is the
cold place second planet ringed one
Prevention
Mercury
Mercury is the
smallest planet

Jupiter
Jupiter is the
biggest planet

Neptune
Neptune is the
farthest planet
 Treatment

Do you know what helps you make your

point clear? Lists like this one:
● They’re simple
● You can organize your ideas clearly
● You’ll never forget to buy milk!

And the most important thing: the

audience won’t miss the point of your
presentation
Awesome
Words
 Recommendations

Don’ts Dos
● Here you can describe ● Here you can describe
what the patient what the patient should
shouldn’t do do
● Here you can describe ● Here you can describe
what the patient what the patient should
shouldn’t do do
● Here you can describe ● Here you can describe
what the patient what the patient should
shouldn’t do do
Prevalence

Mercury
Mercury is the
smallest planet

Jupiter
Jupiter is the
biggest planet
 Conclusions

Mercury
Mercury is the closest
planet to the Sun and
the smallest one in the
Solar System
 Our Team

John James Jenna Doe Jim Patterson

Here you can talk a Here you can talk a Here you can talk a
bit about this bit about this bit about this
person person person
 References

● Author (year). Title of the publication. Publisher

● Author (year). Title of the publication. Publisher
● Author (year). Title of the publication. Publisher
● Author (year). Title of the publication. Publisher
● Author (year). Title of the publication. Publisher
 This Is a Table

Surface
Mass Diameter
Gravity
(earths) (earths)
(earths)

Mercury 0.06 0.38 0.38

Mars 0.11 0.53 0.38

Saturn 95.2 9.4 1.16

 A Timeline Always Works Well

Mercury Mars
Mercury is the Mars is a very
smallest planet cold place

01 02 03 04

Jupiter Neptune
Jupiter is the Neptune is the
biggest planet farthest planet
4,498,300
Big numbers catch your audience’s attention
 Sneak Peek

Mercury
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