Askep Cholecystitis &

Cholelithiasis

Ns. Santi Damayanti,M.Kep.,Sp.Kep.M.B

Review Anfis
• Kandung empedu
(vesika fellea/vesika biliaris)
• suatu kantong yang berdinding
tipis,bentuk seperti buah pir
• Panjang 8-12 cm, lebar 4-5 cm
• Mampu menampung 30-50 ml
cairan empedu
• Fungsi : mengumpulkan dan
memekatkan empedu
• Pigmen empedu : bilirubin dan
biliverdin (urobilin)
Kandung Empedu
Saluran Empedu

• Empedu keluar dari hati

mencapai duodenum
melalui saluran empedu
• Diameter saluran empedu
sebesar pensil
• Kandung empedu  duktus
sistikus  duktus
hepatikus komunisduktus
choledukusampula
hepato pankreatika
papila duodenalis mayor
duodenum
 FISIOLOGI (Guyton &Hall, 1997)
• Fungsi primer kandung empedu memekatkan empedu
• cairan empedu dalam kandung empedu lebih pekat 5-10 x
lipat daripada empedu hepatik dan mengurangi
volumenya 80-90%
• Secara berkala kandung empedu akan mengosongkan
isinya ke dalam duodenum melalui kontraksi simultan
lapisan ototnya dan relaksasi sfingter Oddi.
 Empedu
Fungsi empedu
• Komposisi - mengemulsi lemak  mudah
Empedu : dicerna
1. Air 97 %, - merangsang gerak pristaltik
usus
2. pigmen bilirubin,
- mengubah zat yang tak larut
biliverdin, dan
urobilin dalam air diubah menjadi zat
yang larut dalam air
• 2. Garam-garam
- membantu daya absorbsi lemak
empedu.
pd dinding usus
- menetralisir racun.
Askep Kolelitiasis
 Insiden kolelitiasis
• Di Amerika Serikat diperkirakan 20 juta orang (5
juta pria &15 juta wanita).
• Pada pemeriksaan autopsy di Amerika, ditemukan
pada 20 % wanita dan 8 % pria.
• Insiden kolelitiasis di negara barat banyak
menyerang orang dewasa dan usia lanjut.
• Insiden di Indonesia belum diketahui dengan
pasti(belum ada penelitian) tanpa gejala &
ditemukan secara kebetulan saat foto polos
abdomen, USG,/saat operasi untuk tujuan yang
lain.
 KOLELITIASIS
Definisi :
Penyakit akibat terbentuknya batu empedu
Anonim : batu empedu, gallstones, biliary
calculus
Etiologi :
• Akibat metabolisme abnormal garam
empedu & kolesterol
• Infeksi bakteri
• Stasis empedu
Faktor Resiko

• Jenis kelamin : perempuan mempunyai

risiko 3x lipat : Kehamilan/multiparitas,
pada kontra sepsi oral, terapi post
menopouse. estrogen causing
increased cholesterol secretion, and
progesterone causing bile stasis.
• Umur : usia > 40 tahun
• Obesitas
• Faktor genetik
• Diet tinggi kalori, tinggi kolesterol
Those who are most at risk.

4F

FAMILY FAT FOURTY FEMALE

 Patofisiologi
Ggn metabolisme Infeksi bakteri ggn kontraksi
Empedu & kolesterol /spasme sfingter
Deskuamasi sel
Sekresikan empedu & pembentukan statis kandung
& kolesterol yg jenuh mukus
empedu

Kolesterol mengendap Viskositas empedu supersaturasi

Dalam kandung empedu & perubahan
susunan kimia

pengendapan & pembentukan batu

 Jenis Batu

• Batu kolesterol murni :

kecil, majemuk, hitam, mengandung lebih dari 70%
kolesterol
• Batu kolesterol campuran :
besar, soliter, bulat,oval, warna kuning pucat
• Batu kalsium bilirubinan (pigmen coklat):
sering ditemukan,warna coklat tua, majemuk, kalsium-
bilirubinat sebagai komponen utama.
Batu Cholesterol murni
Batu Kolesterol campuran
Batu kalsium bilirubinan
 Manifestasi klinis

• Demam • Nyeri hebat mid

epigastric/kuadran
• Ikterus kanan atas
• Diaphoresis • Nyeri menjalar ke
• nusea punggung,skapula
kanan, sering muncul
ketika setelah makan
lemak
• Kembung
• Rasa penuh di
epigastrium
Pain
 Symptoms and clinical signs
1. Murphy's symptoms is a delay of breathing
during palpation of gall-bladder on inhalation.
2. Kehr's symptom is strengthening of pain at
pressure on the area of gall-bladder, especially
on deep inhalation.
3. Ortner's symptom — painfulness at the easy
pushing on right costal arc by the edge of palm.
4. Mussy's symptom — painfulness at palpation
between the legs (above a collar-bone) of right
nodding muscle.
 Pemeriksaan penunjang
• USG abdomen
• CT-scan abdomen
• Ro abdomen
• Cholesistogram
• Laboratorium :
• Peningkatan bilirubin
total
• urine bilirubin
• Pemeriksaan faeces
Abdominal X-ray
 Penatalaksanaan

• Konservatif :
• Bedrest
• Pembatasan intake oral
• Pasang NGT  jika muntah
• Diet rendah lemak
• Cairan IV,
• analgetik, anti kolinergik-antispasmodik & antibiotik
• Biliary lithotripsy
• Operatif :
• Kolisistektomi
• Koledokolitomi
Biliary lithotripsy
Tindakan operatif
Laparaskopi Kolisistektomi
Laparaskopi Kolisistektomi
.

Cholecystectomy
or
Laparoscopic Cholecystectomy
– removal of the gallbladder.

This is the treatment of choice.

The gallbladder along with the cystic
duct, vein and artery are ligated.
Laparatomi
Kolisistektomi
 Diagnosa Keperawatan
1. Pain acute r/t :
Biological injuring agents: obstruction/ductal spasm,
inflammatory process, tissue ischemia/necrosis
2. Fluid Volume, risk for deficient r/t :
Excessive losses through gastric suction; vomiting,
distension, and gastric hyper­motility
3. Imbalanced Nutrition: Less Than Body Requirements
r/t :
nausea/vomiting, dyspepsia, pain,
 Nursing Interventions
Post Op - Cholesystectomy

1. Administer oral analgesics to facilitate movement

and deep breathing – and to stay ahead of pts pain.

2. Observe dressings frequently for exudate and hemorrhage.

3. Vitals are routinely checked.

4. Patient teaching:
-Must understand how to splint the abd. before
coughing.
-Report any abnormalities such as, 5. Fluid balance is maintained IV –
severe pain, tenderness in RUQ, increase in potassium added to compensate
pulse, etc . . for loss from surgery.
-Instructed that they usually can return to work in 3
days & can resume full activity in 1 week.
 Nursing Interventions

Interventions center on keeping patient comfortable by

carefully administering meds and watching for reactions.

1. Urine and stool should be observed for alterations

in the presence of bilirubin.

2. NG tube must be monitored for amount, color & consistency

of output.
Also, tube must be on LOW suction and nasal area should
be monitored for irritation and necrosis.

3. Anti-emetics may be administered if nausea persists.

4. I & O are measured and described carefully.

5. Pt. must understand how to splint the abdomen

for post op coughing, turning and deep breathing.
 Kolesistitis
• Kolesistitis akut :
Reaksi inflamasi akut dinding
kandung empedu
• Kolesistitis kronis :
keadaan dimana mukosa & jaringan
otot polos kandung empedu di ganti
dengan jaringan ikat, akibat
kolesistitis, sehingga kehilangan
kemampuan memekatkan empedu
Etiologi
• Batu empedu 90%
• Escherichia coli
• Salmonela typosa
• Cacing ascaris
• Enzim-enzim pankreas
• This infiltration causes an
inflammatory process – the
gallbladder becomes enlarged
and edematous.
• Eventually this occlusion along
with bile stasis causes the
mucosal lining of the gallbladder
to become necrotic.
• Bacterial growth occurs due to
ischemia.

Necrotic
Gallbladder
 • Rupture of the gallbladder becomes a danger, along with spread
of infection of the hepatic duct and liver.
• If the disease is severe and interferes with the blood supply it
can cause the gallbladder to become gangrenous.

Gangren
ous
gallbladd
er Gallston
es
 Manifestasi klinis

• Ikterus
• Mual
• Nyeri perut
• Muntah
bertambah , bila
• Nyeri perut kanan atas makan banyak lemak
• Rasa tidak enak
epigastrium
• Nyeri menjalar kebahu /
subskapula
• Demam
• Nyeri tekan
• Defans muskuler
Signs and Symptoms.
• Complaints of indigestion after
eating high fat foods.
• Localized pain in the right-
upper quadrant epigastric
region.
• Anorexia, nausea, vomiting
and flatulence.

 Increased heart and respiratory rate –

causing patient to become diaphoretic
which in turn makes them think they
are having a heart attack.
 Intervensi cholecystectomy
• Pre operasi :
Monitor balance cairan & status gizi : vit.
K, transfusi darah, suplemen glukosa &
protein 24 jam sebelum operasi.
• Post operasi :
• Atur posisi semi fowler
• Monitor jumlah & warna drainage abdomen/
NGT
• Monitor VS, intake & output tiap 8 jam
(tampung urine & faeces untuk pemeriksaan
lab)
Intervensi cholecystectomy
• Jika NGT sudah dilepas berikan
makanan bertahap :cair,lunak,semi
padat
• Monitor keadaan balutan & ganti
balutan tiap hari
• Bantu ambulasi pada hari pertama
postoperasi, jika tdk ada kontraindikasi
Penkes
• Jelaskan tanda ostruksi saluran empedu:
demam, ikterik, pruritus, nyeri abdomen,
urine gelap,warna faeces pekat.
• Ajurkan untuk diet rendah lemak, tinggi
karbohidrat & protein
• Jelaskan bahwa kemampuan pencernaan
berangsur pulih kurang lebih dalam 6
minggu
 Diagnosa Keperawatan

1. Nyeri Akut b/d :

• Distensi abdomen
• Inkontinuitas jaringan (insisi bedah)
• Peradangan kandung empedu
2. Kekurangan volume cairan b/d :
• Perdarahan
• Mual, muntah
3. Ketidakseimbangan nutrisi : kurang dari
kebutuhan b/d :
• Anoreksia,mual,muntah
• Diet restrection