ASKEP COLOREKTUM

7/25/2019 ASKEP COLOREKTUM

1/47

ASUHAN KEPERAWATAN

KLIEN DENGAN CA COLON

By:

Group 6th(The Enterprenure Group!


2/47

KOLON DAN REKTUM


3/47

An"to#$ Ko%on


4/47

An"to#$ Re&tu#


5/47

'$$o%o$ Ko%on ) Re&tu#

'un$ Ko%on:"*or*$ "$r+ ,$t"#$n-"n e%e&tro%$t

Kontr"&$ &o%ore&t"%-$pen"ruh$ p%e&u"r". $ntr$n$/

Re&tu# nor#"%ny"&oon -"n &et$&"eeor"n *"nun

t$-ur -"n #"&"np"$ #en$#*u%&"n#ot$%$t" &o%on &$r$+.ee #e#"u&$

re&tu# -"n or"ntere*ut #er""$n$n -e.e&"$


6/47

H$to%o$ Ko%on


7/47

KANKER KOLOREKTAL


8/47

KEGANASAN PERINGKAT KE01 DI USADI INDONESIA

KARSINO2A KOLON PERINGKAT KE03KARSINO2A REKTU2 PERINGKAT KE045KARSINO2A KOLO REKTAL PERINGKAT

KE06

INSIDEN PRIA SA2A DENGAN WANITA

(PUSAT DATA DAN IN'OR2ASI KE2ENTERIAN KESEHATAN RI+547!

EPIDE2IOLOGI


9/47

De8n$$

K"n&er &o%ore&t"% #erup"&"n &"n&ery"n #enyer"n &o%on "t"u re&tu#9K"n&er $n$ u" -"p"t -$e*ut &"n&er

&o%on "t"u &"n&er re&t"%+ ter"ntun-$#"n" &"n&er tere*ut ter"-$9 K"n&er&o%on -"n &"n&er re&t"% er$n ter"-$

e/"r" *er"#""n &"ren" #e#puny"$/$r$0/$r$ y"n "#" (A#er$/"n C"n/erSo/$ety+ 54;!9


10/47

Etiologi dan Faktor Risiko

Penye*"* ut"#" -"r$ &"n&er &o%ore&t"%*e%u# -$&et"hu$ e/"r" p"t$9

(S#e%t


11/47

'"&torR$$&o

D"p"t-$u*"

h

D$et

A&t$,$t"'$$&O*e$t

"2ero&o

&

T$-"&-"p"t-$u*"h

U$"Po%$pKo%on

In="##"tory Bo>e%D$e"eGenet

$&


12/47

K%"$8&"$ Po%$p Ko%on


13/47

P"to8$o%o$

K"n&er p"-" &o%on -"n re&tu# -$">"%$-en"n "-"ny" r$>"y"t po%$p9 Po%$p#erup"&"n #"" -"r$ "r$n"n y"n

#enono% p"-" %u#en uu (S#e%t


14/47

St"-$u#


15/47

K%"$8&"$ K"n&er Ko%ore&t"%

(De,$t"+ et "%9+547!


16/47

2"n$.et"$ K%$n$

Ke%uh"n y"n er$n&ont$p"$

Ke%uh"n &"%$*er .ee#ee/$%

Ke%uh"n o*tru&$

S$."t tu#orTu#*uh "nu%er -"n

&ontr$&t$n eh$n"#enye*"*&"n o*tru&$

K"r$n$#" &o%on &$r$


17/47

K"r$no#" &o%on &"n"n

Nyer$ tu#pu%

Ter"*" #"" p"-"perut &"n"n *">"h Ane#$" Ser$n -$"re


18/47

K"r$no#" Re/tu#

Ber"& -"r"h -"n%en-er

Ber"t *"-"n

#enurunTene#u

Ser$n -$-$"no"e*""$ he#orho$-


19/47


20/47

Ko#p%$&"$

49 O*tru&$ uu p"r$"% "t"u %en&"p9

9 2et"t"e &e or"n e&$t"r+ #e%"%u$he#"toen+ %$#.oen -"npenye*"r"n %"nun9

19 He#orr"$9

;9 A*e9

79 Per$ton$t$ -"n "t"u ep$ -"p"t#en$#*u%&"n yo&


21/47

PEMERIKSAAN

Pe#er$&""n '$$&

Pe#er$&""n

D$"not$

&


22/47

Pe#er$&""n '$$&

49 Pe#er$&""n A*-o#en

9 Co%o& Du*ur

P"-" pe#er$&""n $n$ y"n h"ru-$n$%"$:

-. Ke"-""n tu#or

-.

2o*$%$t" tu#or-. E&ten$ pen"%"r"n


23/47

Pe#er$&""n D$"not$&

49 En-o&op$

9 CT S/"n -"n 2RI

19 B"r$u# Ene#";9 CEA (C"r/$no E#*r$on$& Ant$en!

S/reen$n


24/47

Pen"t"%"&"n""n

49 Pen"t"%"&"n""n #e-$

Ke#oter"p$ Ter"p$ r"-$"$

Ko#*$n"$


25/47

9 Pen"t"%"&"n""n Be-"h

Ree&$ e#ent"%


26/47


27/47


28/47


29/47

Ko%oto#$


30/47

Pen"t"%"&"n""nKeper">"t"n

"9 2e#pert"h"n&"n e%$#$n"$ p"$en

*9 2e#pert"h"n&"n "t"u #en$n&"t&"n&eny"#"n"n

/9 2en$n&"t&"n to%er"n$ "&t$,$t"

-9 2e#*"ntu pe#*er$"n nutr$$ opt$#"%

e9 2e#pert"h"n&"n &ee$#*"n"n /"$r"n

-"n e%e&tro%$t.9 2e%"&u&"n per">"t"n &u%$t+ %u&" -"n

&o%oto#$ (p"/" *e-"h!


31/47

KONSEP ASUHANKEPERAWATAN


32/47

Pen&"$"n

I-ent$t" Ke%uh"n ut"#"

Nyer$ p"-" -"er"h "*-o#en "t"u

re&t"%+ &eu%$t"n -"%"# #e%"&u&"n*u"n "$r *e"r -"n per-"r"h"np"-" "nu9

R$>"y"t peny"&$t e&"r"n R$>"y"t peny"&$t -"hu%u

R$>"y"t peny"&$t &e%u"r"


33/47

Pe#er$&""n '$$&

B1 Br!at"ing#

D"-" $#etr$+ t"&t$% .re#$tu &"n"n0&$r$ "#"+ ,e$&u%er+ RR 4605&"%$?#en$t+ t$-"& "-" /up$n h$-un+ t$-"& "-" penun""n ototpern"p""n t"#*"h"n9

B$ Blood#

TD 45?@5 ##H+ N"-$ 650@5 &"%$?#en$t+ n"-$ ter"*" &u"t+ "&r"% h"n"t+CRT -et$&9

B% Brain#

Co#po#ent$ -en"n GCS 47+ E; 7 26+ re"&$ pup$% $o&or 1?(&"n"n!+ 1? (&$r$!+ re=e& /"h"y" ?

B& Bladd!r#

're&uen$ BAK + >"rn" -"n pro-u&$ ur$n+ terp""n &"teter "p" t$-"&9

B' Bo(!l#

Bentu& perut ""& /e#*un+ per$t"%t$& per#en$t+ ter-"p"t &ont$p"$ ?-$"re+ *uny$ re-up ? onor+ -u%%ne+ "-"ny" nyer$ te&"n ? t$-"&9

B) Bon!#

E&tre#$t" "t" : Ke&u"t"n otot &"?&$ : 6?6+ RO2 &"?&$ : "&t$.?"&t$.

E&tre#$t" *">"h : &e&u"t"n otot &"?&$: 6?6+ RO2 &"?&$ : "&t$.?"&t$.


34/47

D$"no" Keper">"t"n

49 Kont$p"$ *9- penurun"n "up"n/"$r"n -"n er"t+ &e%e#"h"n otot"*-o#en e&un-er "&$*"t C"

Co%ore/t"%99 D$"re *9- proe peny"&$t9

19 Nyer$ "&ut *9- proe peny"&$t9

;9 Ket$-"&e$#*"n"n nutr$$ &ur"n -"r$&e*utuh"n tu*uh *9- #u"%?#unt"h9

79 An$et" *9- proe peny"&$t


35/47

KASUS


36/47

Tn9 C (;7 th! -"t"n &e po%$&%$n$& RSUD Dr9 Soeto#o -n&e%uh"n nyer$ -$ -"er"h perut *"$"n &$r$ *">"h9 Su-"h 1#$nu $n$ BAB ny" e%"%u *er%en-$r -"n *er-"r"h+ 4#$nu ter"&h$r $n$ BAB ny" *er-"r"h e"r er$n u"#en"%"#$ o*t$p"$+ &"-"n u" #en"%"#$ &e#*un+&%$en #er"" *"h>" BBny" turun (BB ">"% 35 &!+ t$-"&n".u #"&"n+ #u"%+ #unt"h -"n u" nyer$ ""t BAB9

K%$en #en"t"&"n t$-"& t"hu peny"&$t "p" y"n-$-er$t"ny" ""t $n$9 Ke%u"r" #en"t"&"n p"$en %e*$hen"n #"&"n -"$n+ "y"# -"n "r"n #"&"n "yur9

S""t pe#er$&""n 8$& -$-"p"t -"t" : KU %e#"h+ TT4;5?F5 ##H+ N: 455?#en$t+ uhu 13+;5C + RR :

5?#en$t+ /onunt$," "ne#$+ -$ten$ "*-o#en+ nyer$te&"n -$ "*-o#en9 H"$% /o%ono/opy: *er*entu& $r&u%er-"n "nu%er -"n penye#p$t"n %u#en uu -"n tr$&tur"#enono% -"n #en$$9 K%$en -$-$"no$ C" Co%on9


37/47

Pen&"$"n

49 An"#ne""9D"t" De#or"8 K%$en

*9Ke%uh"n ut"#"

K%$en #ene%uh nyer$ -$ -"er"h perut *"$"n &$r$

*">"h/9 RPS

K%$en #ene%uh u-"h 1 #$nu BABny" *er%en-$r-"n *er-"r"h -"n 4 #$nu ter"&h$r $n$ BAB ny"-"r"h e"r9 K%$en er$n #en"%"#$ o*t$p"$+&"-"n u" #en"%"#$ -$ten$ "*-o#en+ u-"h4 *u%"n $n$ BB &%$en turun (BB ">"% 35 &!+ t$-"&n".u #"&"n -"n u" nyer$ ""t BAB


38/47

-9 RPD

T$-"& "-" r$>"y"t >"$r

e*e%u#ny" Ser$n &ont$p"$

Per"""n *u"n "$r *e"r t$-"&

tunt"e9 RPK

R$>"y"t &e%u"r" t$-"& pern"h

#en-er$t" &e%uh"n y"n "#"-en"n y"n -$-er$t" &%$en9


39/47

9 Pe#er$&""n '$$&B1 Br!at"ing# B!nt*k dada si+!tris, RR $- kali . +!nit, tidak

ada /!ngg*naan otot 0ant* /!rna/asan, tidakada r!traksi dinding dada, s*ara na/as

!sik*l!r2B$ Blood#

A&r"% ter"*" h"n"t+ TD 4;5?F5 ##H+ n"-$ ter"*"

&u"t+ n"-$ 455 &"%$?#en$t+ CRT -et$&+ T: 13+;oC+

/onunt$," "ne#$

B% Brain#

Ke"-"r"n /o#po#ent$ -en"n GCS 47+ E ; 7 2 6+ re"&$ pup$% $o&or 1? ( &"n"n !+1? ( &$r$ !+

re=e& /"h"y" ? B& Bladd!r#

B$""ny" BAK 706 ?h"r$ pont"n9

B' Bo(!l# BAB ter"&h$r *er%en-$r -"n -"r"h e"r -"n er$n

u" #en"%"#$ o*t$p"$+ nyer$ ""t BAB+ -$ten$

"*-o#en+ BB &%$en turun #en"-$ 76 & (BB ">"% 35

&!+ t$-"& n".u #"&"n

B) Bon!# E&tre#$t" "t" :

T$-"& "-" o-e#"+ tonu otot 7+ CRT -t&+ t$-"&

"-" %e$9

E&te#$t" *">"h:

T$-"& "-" o-e#"+ tonu otot 7+ CRT -t&9


40/47

Pe#er$&""n Penun"n

Co%ono/opy: *er*entu& $r&u%er -"n"nu%er -"n penye#p$t"n %u#en uu-"n tr$&tur" #enono% -"n #en$$


41/47

An"%$" D"t"No

2

SI4N AND S5MPTOM ETIOLO

4I

PROBLEM

12 DS:

- P"$en #en"t"&"n u-"h 1

#$nu $n$ BAB ny" e%"%u

*er%en-$r -"n *er-"r"h+

-P"$en #en"t"&"n 4 #$nuter"&h$r $n$ BAB ny" -"r"h

e"r

- P"$en #en"t"&"n nyer$

""t BAB -"n #en"%"#$

o*t$p"$

DO:

- KU %e#"h

-TT 4;5?F5 ##H+ N:

455?#en$t+ uhu 13+;5C +

RR : 5?#en$t+

-Conunt$," "ne#$

- Co%ono/o : *er*entu&

G"nu"n

"tro$ntet$

n"%

Re$&o

Per-"r"h"n


42/47

$2 DS 6

- Pasi!n +!ng!l*" n7!ri di da!ra"

/!r*t 0agian kiri 0a(a"

DO6

-Skala n7!ri6 8

- P!rilak* +!lind*ngi ar!a 7ang

sakit dan distraksi

- R!s/on a*tono+ s!/!rti

dia/"or!sis, /!ningatan t!kanan

dara", /!ningkatan nadi#

-Tingka" lak* !ks/r!si9 :onto" 6

g!lisa", +!rinti", +!nangis,

(as/ada, irita0!l, na9as

/an;ang.0!rk!l*" k!sa"#

- N7!ri t!kan /al/asi# /ada /!r*t

0agian kiri 0a(a"- Dist!nsi a0do+!n

- TD6 1&-.


43/47

%2 DS6

- Pasi!n +!ngatakan

s*da" 1 0*lan ini BB

kli!n t*r*n BB a(al 8-kg#

- Pasi!n +!ngatakan tidak

na9s* +akan

- K!l*arga /asi!n

+!ngatakan, +akanan/asi!n tidak "a0is,

"an7a "a0is $ s!ndok

- Pasi!n +!ngatakan

s!ring +!ngala+i +*al

dan +*nta"

DO6- KU l!+a"

- Pasi!n t!rli"at

:on;*ngtia an!+is

- BB6 ') kg

- N7!ri t!kan /al/asi#

/ada /!r*t 0agian kiri

Anor!ksia,

+*al,

+*nta"

K!tidaks!i+0a

ngan n*trisi

k*rang dari

k!0*t*"ant*0*"


44/47

&2 DS6

- Pasi!n +!ngatakan s!ring

s*sa" *nt*k BAB o0sti/asi#

- Pasi!n +!ngatakan tidak

na9s* +akan

-Pasi!n +!ngatakan kadang

;*ga +!ngala+i k!+0*ng

dist!nsi a0do+!n#

- Pasi!n +!ngatakan n7!ri

t!kan /ada a0do+!n

- K!l*arga +!ngatakan /asi!n

l!0i" s!nang +akan daging,a7a+ dan ;arang +akan sa7*r

DO6

- Pasi!n t!rli"at :on;*ngtia

an!+is,

- P!r*t /asi!n t!rli"at agak

+!+0!sar dist!nsia0do+!n#

P!n7!+/itan

l*+!n dan

strikt*r

Konsti/asi

'2 DS: p"$en #en"t"&"n t$-"& t"hu

tent"n peny"&$tny"

DO:

- K%$en er$n *ert"ny" tent"n

peny"&$tny" p"-" per">"t

-K%$en t"#p"& *$nun

Kur"n

$n.or#"$

De8$en$

penet"hu"n


45/47

D$"no" Keper">"t"n

49 Re$&o per-"r"h"n *9- ."&tor re$&o"nu"n "tro$ntet$n"%

9 Nyer$ "&ut *9- "en $nury *$o%o$

19 Ket$-"&e$#*"n"n nutr$$ &ur"n -"r$&e*utuh"n tu*uh *9- "nore&$"+ #u"%+#unt"h

;9 Kont$p"$ *9- penye#p$t"n %u#en -"n

tr$&tur79 De8$en$ penet"hu"n *9- &ur"n

$n.or#"$


46/47

Inter,en$ Keper">"t"n

Seu"$&"n -en"n NOC NIC 5470

543


47/47

TERI2AKASIH

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ASKEP COLOREKTUM