Kolelitiasis Kel. 7

8/12/2019 Kolelitiasis Kel. 7

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ASUHAN KEPERAWATAN PADA PASIEN DENGAN

CHOLELITIASIS

DISUSUN OLEH

KELOMPOK 7


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KELOMPOK 7

5

PROGRAM S1 ILMU KEPERAWATAN

FAKULTAS KEPERAWATAN

UNIVERSITAS AIRLANGGA

2012

BAB II

TINJAUAN PUSTAKA

2.1. Anato! "an F!#!o$o%! S!#t& B!$!&'

a. !*at0mi s#,r#si #m$#"u

Ka*"u* #m$#"u m#ru$a,a* ,a*t0* #r0*a #r#*tu, $ir

'a* t#r-#ta, t#$at "i a)ah -0us ,a*a* hati. Em$#"u 'a* "is#,r#si

t#rusm#*#rus 0-#h hati masu, ,# "a-am ,a*"u* #m$#"u 'a* ,#i-

"a-am hati. Sa-ura* #m$#"u 'a* ,#i- #rsatu m#m#*tu, "ua sa-ura*

-#ih #sar 'a* ,#-uar "ari $#rmu,aa* a)ah hati s#aai "u,tus

h#$ati, s ,a*a* "a* ,iri a* s##ra #rsat m#m#*t , " ,t s h#$ati, s


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"u0"#*um a,iat hasi- $#*#r*aa* "ari $r0t#i* "a* -i$i" "a* ha- i*i

m#ra*sa* t#r>a"i*'a ,0*tra,si ,a*"u* #m$#"u ;Pri# ? (i-s0* 26 i - t " - - , ti" > - t " -


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m#*'#a,a* #s#s #r)ar*a 0,-at. S#,itar 12@ ur0i-i*0#*

m#*a-ami si,-us #*t#r0h#$ati, s#"a*,a* s#>um-ah ,#i- "i#,s,r#si

"a-am uri* ;Pri# ? (i-s0* 26


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$arti,#-$arti,#- -#ma, 'a* #sar "a-am ma,a*a* m#*>a"i a*'a,

$arti,#- ,#i- $#rmu,aa* $arti,#- t#rs#ut "a$at "is#ra* 0-#h #*&im

-i$as# 'a* "is#,r#si,a* "a-am #tah $a*,r#as "a* ;2< asam #m$#"u

m#ma*tu as0rsi $r0"u, a,hir -#ma, 'a* t#-ah "i#r*a m#-a-ui

m#mra* mu,0sa i*t#sti*a-.

K#"ua #m$#"u #,#r>a s#aai suatu a-at u*tu, m#*#-uar,a*

##ra$a $r0"u, ua*a* 'a* $#*ti* "ari "arah. Ha- i*i t#rutama

m#-i$uti i-irui* suatu $r0"u, a,hir "ari $#*ha*ura* h#m0-0i* "a*

,#-#iha* ,0-#st#r0-.

". isi0-0i S#,r#si Em$#"u ;Pri# ? (i-s0* 26um-ah #sar asam #m$#"u

,0-#st#r0- "a* &at&at 0ra*i, -ai**'a. K#mu"ia* #m$#"u "is#,r#si,a*

,# "a-am ,a*a-i,u-i i-iaris ,#i- 'a* t#r-#ta, "i a*tara s#-s#- hati.

2. K#mu"ia* #m$#"u m#*a-ir "i "a-am ,a*a-i,u-i m#*u>u s#$ta

i t - - i t t , -i, -i - , " , " -


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#. P#*'im$a*a* "a* P#m#,ata* Em$#"u "i "a-am Ka*"u* Em$#"u ;Pri#

? (i-s0* 26ua m#mutuh,a*

r#-a,sasi 'a* #rsamaa* "ari si*t#r O""i 'a* m#*>aa $i*tu ,#-uar

"u,tus i-iaris ,0mu*is ,# "a-am "u0"#*um.

S#>auh i*i ra*sa*a* 'a* $a-i* $0t#* m#*'#a,a* ,0*tra,si

, " " " - h h , - i t ,i i H i i ,


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>um-ah 'a* #rarti "a-am ma,a*a* *0rma-*'a ,a*"u* #m$#"u ,0s0*

s#ara m#*'#-uruh "a-am )a,tu s#,itar 1 >am.

h. u*si Caramaram Em$#"u Pa"a P#*#r*aa* "a* !s0rsi L#ma,

;Pri# ? (i-s0* 26um-ah 'a* sama. !samasam i*i s#-a*>ut*'a

a,a* #r,0mi*asi t#rutama "#*a* -isis* "a* "a-am >um-ah 'a* -#ih

s#"i,it "#*a* tauri* u*tu, m#m#*tu, asam #m$#"u t#r,0*>uasi-i,0

"a* taur0. Caramaram "ari asam i*i t#rutama aram *atrium

,#mu"ia* a,a* "is#,r#si "a-am #m$#"u.

Caramaram #m$#"u m#m$u*'ai "ua ,#r>a $#*ti* $a"a tra,tus

i*t#sti*a- A

P#rtama aramaram i*i #,#r>a s#aai "#t#r>#* $a"a $arti,#-

- , " - , H - i i i t , ti, -


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S#,itar 94 @ aram #m$#"u "ir#as0rsi ,# "a-am "arah "ari usus

ha-us s#,itar s#t#*ah*'a "#*a* ara "iusi m#-aui mu,0sa $a"a aia*

a)a- usus ha-us "a* sisa*'a m#-aui tra*s$0r a,ti m#-#)ati mu,0sa usus

$a"a aia* "ista- i-#um. Caram #m$#"u -a-u masu, "arah $0rta- "a*

"it#rus,a* ,#ma-i ,# hati. Pa"a saat m#*a$ai hati $a"a saat $#rtama

-#)at m#-a-ui si*us0i" :#*a aramaram #m$#"u "ias0rsi ,#ma-i

ham$ir s#-uruh*'a $a"a a-ira* $#rtama m#-a-ui si*us0i" :#*a ,#ma-i ,#

"a-am s#-s#- hati "a* ,#mu"ia* "is#,r#si,a* ,#ma-i ,# "a-am #m$#"u.

D#*a* ara i*i s#,itar 94@ "ari s#mua aram #m$#"u

"isir,u-asi,a* ,#ma-i ,# "a-am #m$#"u s#hi*a ratarata aram i*i

a,a* m#*a-ami sir,u-asi s#a*'a, 17 ,a-i s##-um "i,#-uar,a* #rsama

ti*>a. S#>um-ah aram #m$#"u 'a* "i,#-ur,a* ,# "a-am ti*>a a,a* "ia*ti

"#*a* >um-ah aram 'a* aru 'a* "i#*tu, s#ara t#rusm#*#rus 0-#h

s#-s#- hati. Sir,u-asi u-a* aram #m$#"u i*i "is#ut sir,u-asi

#*#t#r0$ati, aramaram #m$#"u.

um-ah #m$#"u 'a* "is#,r#si 0-#h hati s#tia$ hari*'a sa*at

t " t "i " M ,i ,


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S#-ai* ##, $#ra*sa*a* 'a* ,uat "ari asam #m$#"u u*tu,

m#*'#a,a* t#r>a"i*'a s#,r#si #m$#"u h0rm0* s#,r#ti* >ua

m#ra*sa* s#,r#si $a*,r#as m#*i*,at,a* s#,r#si #m$#"u ,a"a*

,a"a* -#ih "ari "ua ,a-i -i$at s#-ama ##ra$a >am s#su"ah ma,a*

P#*i*,ata* s#,r#si i*i ham$ir s#mua*'a a"a-ah "#,r#si -aruta* #*#r

'a* ,a'a *atrium i,ar0*at 0-#h s#- #$it#- "u,tu-us "a* "u,tus #m$#"u

"a* u,a* $#*i*,ata* s#,r#si 0-#h s#-s#- $ar#*,im hati itu s#*"iri.

i,ar0*at ,#mu"ia* a,a* "it#rus,a* ,# "a-am usus ha-us "a* #rau*

"#*a* i,ari*at "ari $a*,r#as u*tu, m#*#tra-,a* asam hi"r0,--0ri"a "ari

-amu*. a"i m#,a*ism# um$a* a-i, s#,r#ti* u*tu, m#*#tra-,a* asam

"u0"#*um #,#r>a ti"a, ha*'a m#-a-ui ##,*'a t#rha"a$ s#,r#si $a*,r#as

t#ta$i >ua "a-am >um-ah 'a* s#"i,it m#-a-ui ##,*'a t#rha"a$ s#,r#si

0-#h "u,tu-us "a* "u,tus hati.

2.2. D&,!n!#! C*o$&$!t!a#!#

/h0-#-itiasis a"a-ah atu #m$#"u iasa*'a "i#*tu, "i "a-am

,a*"u* #m$#"u "ari aha*aha* $a"at #m$#"u "a* sa*at #r:ariasi "a-am

h - t , , " , i i !" " > i t t "


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,-i*is 'a* "i,ait,a* "#*a* s#ma,i* m#*i*,at*'a i*si"#*si atu #m$#"u

a"a-ah "ia#t#s sir0sis hati $a*r#atitis ,a*,#r ,a*"u* #m$#"u "a*

$#*'a,it atau r#s#,si i-#um. a,t0r r#si,0 -ai* 'a* #r,aita* "#*a*

timu-*'a atu #m$#"u a"a-ah 0#sitas mu-ti$aritas $#rtamaha* usia >#*is

,#-ami* $#r#m$ua* "a* i*#sti s##ra ma,a*a* 'a* m#*a*"u* ,a-0ri

r#*"ah atau -#ma, r#*"ah ;$uasaara* "i#*tu, $a"a sa-ura* #m$#"u -ai*.

Eti0-0i atu #m$#"u masih #-um "i,#tahui s#$#*uh*'a a,a* t#ta$i

tam$a,*'a a,t0r $r#"is$0sisi t#r$#*ti* a"a-ah a*ua* m#ta0-ism# 'a*

m#*'#a,a* t#r>a"i*'a $#ruaha* ,0m$0sisi #m$#"u stasis #m$#"u "a*

i*#,si ,a*"u* #m$#"u. P#ruaha* ,0m$0sisi #m$#"u ,#mu*,i*a*

m#ru$a,a* a,t0r t#r$#*ti* "a-am $#m#*tu,a* atu #m$#"u. S#>um-ah

$#*'#-i"i,a* m#*u*>u,,a* ah)a hati $#*"#rita atu #m$#"u ,0-#st#r0-

m#*'#,r#si #m$#"u 'a* sa*at >#*uh "#*a* ,0-#st#r0-. K0-#st#r0- 'a*

#r-#iha* i*i m#*#*"a$ "a-am ,a*"u* #m$#"u ;"#*a* ara 'a* #-um

"im#*#rti s#$#*uh*'a< u*tu, m#m#*tu, atu #m$#"u. Stasis #m$#"u

" - , " " " t ,i t, t i i


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#r)ar*a hitam #r,aita* "#*a* h#m0-isis ,r0*is atu #r)ar*a

,#0,-ata* #r,aita* "#*a* i*#,si #m$#"u ,r0*is ;atu s#maam i*i

>ara* "i>um$ai


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5. Uri*# #r)ar*a sa*at #-a$ #s#s )ar*a $uat.

6. D#isi#*si :itami* ! D E K ;:itami*:itami* 'a* -arut "a-am -#ma,i,a atu

#m$#"u t#rus m#*'umat sa-ura* #m$#"u.

2.3 Pato,!#!o$o%! "an WOC C*o$&$!t!a#!#

/h0-#-itiasis m#*au $a"a atu sa-ura* #m$#"u 'a* ,#a*'a,a*

t#r#*tu, "a-am ,a*"u* #m$#"u itu s#*"iri. aha* umum*'a a"a-ah

,0-#st#r0- $im#* "a* atu #m$#"u s#ri* m#*a*"u* am$ura*

,0m$0*#* #m$#"u. Susu*a* atu #m$#"u t#r"iri "ari ,0-#st#r0- ,a-sium

,ar0*at "a* ,0mi*asi "ari aha* t#rs#ut. Ma*i#stasi ,-i*is atu #m$#"u

#r#ra, "a$at m#*'umat "u,tus i-iaris ,0mu*is. Ostru,si i*i

m#*imu-,a* *'#ri ;,0-i,< "a* m#*ha-a*i #m$#"u ,#-uar ;ama'0*

2


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$r0"u, m#ta0-ism# -#ma, "a-am tuuh. U*tu, a-asa* i*i-ah 0ram 'a*

m#-a,u,a* "i#t ti*i -#ma, "a-am )a,tu #rtahu*tahu* a,a* mu"ah

m#*a-ami $#m#*tu,a* #m$#"u.

P#ra"a*a* #$it#- ,a*"u* #m$#"u 'a* s#ri*,a-i #rasa- "ari

i*#,si ,r0*is "#ra>at r#*"ah >ua "a$at m#*uah ,ara,t#risti, as0rsi

mu,0sa ,a*"u* #m$#"u ,a"a* m#mu*,i*,a* as0rsi #r-#iha* "ari air

"a* aramaram #m$#"u ta$i m#*i*a-,a* ,0-#st#r0- "a-am ,a*"u*

#m$#"u "a-am ,0*s#*trasi 'a* m#*i*,at s#ra $r0r#si. La-u ,0-#st#r0-

a,a* mu-ai m#*#*"a$ $#rtama a,a* m#m#*tu, a*'a, ,rista- ,0-#st#r0-

,#i- $a"a $#rmu,aa* mu,0sa 'a* m#*a-ami $#ra"a*a* ta$i #r-a*>ut

m#*>a"i atu #m$#"u 'a* #sar.

(O/A t#r-am$ir

2.6 P&&'!+#aan P&n)n7an% C*o$&$!t!a#!#

M#*urut D0#*0#s ;2a* 'a* "iu*a,a*

a"a-ah s#aai #ri,utA

a. #s -a0rat0rium A

1< L , it 12 15 i ;N - 5 1 i


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Sasara* utama t#ra$i m#"i,a- a"a-ah u*tu, m#*ura*i i*si"#*

s#ra*a* a,ut *'#ri ,a*"u* #m$#"u "a* ,0-isistitis "#*a*

$#*ata-a,sa*aa* su$0rti "a* "iit s#rta >i,a m#mu*,i*,a* u*tu,

m#*'i*,ir,a* $#*'#a "#*a* arma,0t#ra$i $r0s#"ur$r0s#"ur

#*"0s,0$i atau i*t#r:#*si $#m#"aha*.

1< M#*ha*ur,a* atu #m$#"u "#*a* m#*i*us $#-arut ,#"a-am

,a*"u* #m$#"u.

2< M#*a*,ut atu #m$#"u m#-a-ui #*"0s,0$i E%/P.

. P#*ata-a,sa*aa* "iit "a* su$0rti

1< M#*a$ai r#misi "a* istirahat aira* IF $#*hisa$a* *as0astri,

;NC


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m#*>a-ar ,#-uar -#)at -u,a 0$#rasi u*tu, m#*a-ir,a* "arah aira*

s#r0sa*ui*us "a* #tah #m$#"u ,#"a-am ,assa as0r#*.

3< Mi*i,0-#sist#,t0mi m#*#-uar,a* ,a*"u* #m$#"u -#)at -u,a i*sisi

s#-#ar 4 m isa "i$asa* "rai* >ua ia'a -#ih ri*a* )a,tu

si*,at.

4< K0-isist#,t0mi #*"0s,0$i "i-a,u,a* -#)at -u,a i*sisi ,#i- atau -u,a

tusu,a* m#-a-ui "i*"i* a"0m#* $a"a umi-ius.

2.9 Ko($!+a#! C*o$&$!t!a#!#

K0m$-i,asi 'a* umum "i>um$ai a"a-ah ,0-#sistitis a,ut $a*,r#atitis

a,ut #mi#ma "a* $#r0rasi ,a*"u* #m$#"u ;Custa)a* #t a- 27 i " - " , i i, ;K - , 212<


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0ra* s#,#-i-i* "a* 0m#*tum "a-am "a#rah :#si,a i-iaris 'a*

m#ra"a* r#a,si -0,a- i*i ##,ti m#mu*,us "a#rah $#r0rasi "a-am

"i*"i* :#si,a i-iaris.

2< P#r0rasi i*tra$#rit0*#um #asA ,0m$-i,asi timu- s##-um $#r-#,ata*

$#ra"a*a* -0,a-. S#ara ,-i*is $asi#* ti"a, isa m#*,0m$#*sasi

$#ruaha* "ari *'#ri ,ua"ra* ,a*a* atas ,# ta*"a $#rit0*#um

#*#ra-isata. #ra*tu* $a"a -uas i*:asi a,t#ri $asi#* i*i m#*"#rita

$#rit0*itis #m$#"u #*#ra-isata $arah. I*t#r:#*si #"ah harus s##ra

"i-a,u,a*.

3< istu-a ,0-#sist0#*t#ri, s$0*ta*A isa timu- i-a $#ra"a*a* a,ut

:#si,a i-iaris m#*'#a,a* $#r-#,ata* s#r0sa 'a* #rat ,# :is,us

#r0*a s#,#-i-i**'a $a-i* s#ri* a"a-ah "u0"#*um atau ,0-0*.

P#ruaha* a*r#*0sa a,uta ;atau t#,a*a* m#*ahu* *#,r0sis a,iat

atu #m$#"u< m#*>a"i $#r0rasi t#r,#*"a-i ,# "a-am -um#* :is,us

'a* m#-#,at ;Saist0* 1994u,,a* i*#,si a,t#ri i*:asi:# "ari ata*

- " " > - i i i, , i i, i


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. I-#us atu #m$#"uA atu #m$#"u 'a* masu, ,# i-#us. I*-amasi 'a*

#rat "ari ,a*t0* #m$#"u m#*'#a,a* istu- "ari sa-ura* #m$#"u ,#

"u0"#*um atau usus ha-us 'a* m#*'#a,a* atu #m$#"u masu, ,#

tra,tus astr0i*t#sti*a-. atu #m$#"u 'a* #sar "a$at t#r>#$it "i usus

ha-us umum*'a $a"a aia* i-#um t#rmi*a- atau ,atu$ i-#0a#a- 'a*

m#*'#a,a* 0stru,si ;ara"i--a 29


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BAB III

KONSEP ASUHAN KEPERAWATAN PADA

PASIEN DENGAN CHOLELITIASIS

-.1 P&n%+a7!an

1. I"#*titas $asi#*

atu #m$#"u ti"a, -a&im "i>um$ai $a"a a*a,a*a, "#)asa mu"a

i i i" ,i i i "i i" i "i 4 h I i"


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Ca*ua* #$iastrium s#$#rti rasa $#*uh "ist#*si a"0m#* "a* *'#ri

'a* samar $a"a ,ua"ra* ,a*a* atas a"0m#* "a$at t#r>a"i. Ca*ua* i*i

"a$at t#r>a"i s#t#-ah i*"i:i"u m#*,0*sumsi ma,a*a* 'a* #r-#ma,

;Sm#-tr ? ar# 22


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Tanda: N'#ri -#$as. 0t0t t#a* atau ,a,u i-a ,ua"ra* ,a*a* atas

"it#,a*A ta*"a Mur$h' $0siti

". Sist#m #*it0uri*arius.

Gejala: P#ruaha* )ar*a uri*# "a* #s#s.

Tanda: Dist#*si a"0m#*. #raa masa $a"a ,ua"ra* ,a*a* atas.

Uri*# #-a$ $#,at #s#s )ar*a $uat. st#at0r#a.

#. Sist#m sara.

i"a, a"a

. Sist#m -0,0m0t0rmus,u-0s,#-#ta-.

i"a, a"a ,#-ai*a*

. Sist#m #*"0,ri*.

Ostru,si a-ira* #m$#"u m#*a*u as0r$si :itami* ! D E "a*

K 'a* -arut -#ma,.

h. Sist#m i*t#um#*.

D#mam #r,#ri*at ata- ;$ruritus


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". %asa s#$#rti t#ra,ar $a"a #$iastri, ;h#art ur*


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5. %#si,0 $#*"araha* " a*ua* $#m#,ua* "arah

-.- Int&';&n#! K&(&'a:atan

1. N'#ri a,ut " $r0s#s $#*'a,it a"a*'a atu

NOC A Status *'ama* A isi,

u>ua* A Pasi#* mam$u m#*a$ai -#:#- *'ama* s#t#-ah "i-a,u,a*

ti*"a,a* ,#$#ra)ata*.....hari $#ra)ata*.

Krit#ria hasi- A

No. In"!+ato' 1 2 - 5

1.

2.

3.

4.

5.

K0*tr0- #>a-a

K#*'ama*a* isi,

%#-a,sasi 0t0t

P0sisi *'ama*

L#:#- #*#ri

K#t#ra*a* A

1. i"a, $#r*ah DN 4. S#ri* DN

2. ara* DN 5. S#-a-u DN

3. Ka"a* DN

NIC A Ma*a#m#* *'#ri


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2. K#ti"a,s#ima*a* *utrisiA ,ura* "ari ,#utuha* tuuh " mu*tah "a*

$#*uru*a* asu$a* *utrisi.

NOC A Status *utrisi A i*ta,# ma,a*a* "a* mi*uma*

u>ua* A Pasi#* mam$u m#*a$ai status *utrisi A i*ta,# ma,a*a*

"a* mi*uma* 'a* a"#,uat s#t#-ah "i-a,u,a* ti*"a,a* ,#$#ra)ata*.....hari

$#ra)ata*.

Krit#ria hasi- A

No. In"!+ato' 1 2 - 5

1.

2.

3.

4.

I*ta,# ma,a*a* $#r 0ra-

I*ta,# aira* $#r 0ra-

I*ta,# *utrisi $ar#*t#ra-

I*ta,# *utrisi $#r NC

NIC A Ma*a#m#* *utrisi

!,ti:itas A

1. S#su"ah s#-a* *as0astri, "i-#$as ,0-a0rasi,a* "#*a* "0,t#r

u*tu, m#mu-ai "i#t air >#r*ih 'a* "i-a*>ut,a* "i#t -u*a, r#*"ah

-#ma, u*tu, m#*ura*i stimu-asi ,a*"u* #m$#"u "a* *'#ri 'a*

"itimu-,a* s#rta ,#mu*,i*a* ,amuh ,#ma-i


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,#ma* ,0- u*is mi*uma* s0"a "-- hi*"ari ma,a*a* #rumu

$#"as ,a#i* s#mua >#*is >#ru, 'a* m#*iritasi mu,0sa -amu*

a*>ur,a* $asi#* "a* 0ra* t#r"#,at u*tu, m#*i*,at,a* ,a*"u*a*

-#ma, "a-m "i#t s#ara $#r-aha*.

11. Dis,usi,a* $#r-u*'a $#*uru*a* #rat a"a*

12. Dis,usi,a* $#*ti**'a istirahat ,husus*'a s#su"ah ma,a*

3. %#si,0 ,#rusa,a* i*t#ritas ,u-it " i,t#rus.

NOC A I*t#ritas >ari*a* A Ku-it "a* m#mra* mu,0sa

u>ua* A Pasi#* mam$u m#*hi*"ari r#si,0 ,#rusa,a* i*t#ritas

,u-it s#t#-ah "i-a,u,a* ti*"a,a* ,#$#ra)ata*.....hari

Krit#ria hasi- A

No. In"!+ato' 1 2 - 5

1.

2.

Suhu ,u-it

S#*sasi


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u>ua* A Pasi#* mam$u m#mahami $r0s#s $#*'a,it "a*

$#*ata-a,sa*aa* "ari $#*'a,it h0-#-itiasis

Krit#ria hasi- A

No. In"!+ato' 1 2 - 5

1.

2.

3.

4.5.

6.

7.

8.

Pr0s#s $#*'a,it s$#sii,

a,t0r $#*'#a "a* $#*#tus

a,t0r r#si,0

E#, $#*'a,ita*"a "a* #>a-a "ari $#*'a,it

P0t#*sia- ,0m$-i,asi "ari $#*'a,it

P#*#aha* ,0m$-i,asi

P#*ata-a,sa*aa* $#*'a,it

NIC A M#*a>ar A Pr0s#s $#*'a,it ; #ahi*A Dis#as# Pr0#ssi u-a* "a* "is,usi,a* $r0s#s $#*'a,it s#$#rti 'a* t#-ah "i>#-as,a*

0-#h "0,t#r #ri ,#s#m$ata* $asi#* atau ,#-uara #rta*'a.

2. Ka>i u-a* ta*"a "a* #>a-a 'a* harus "i$#rhati,a* misa-*'a "#mam

mua-mu*tah *'#ri i,t#rus ata- uri*# #-a$ $#r"araha* m#mra*

mu,0sa "arah "a-am #s#suri* "a* #s#s #r)ar*a "#m$u-.


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5. %#si,0 $#r"araha* " a*ua* $#m#,ua* "arah.

NO/ A K0*tr0- r#si,0

u>ua* A Pasi#* mam$u m#*0*tr0- r#si,0 $#r"araha* s#t#-ah

"i-a,u,a* ti*"a,a* ,#$#ra)ata*....hari

Krit#ria hasi- A

No. In"!+ato' 1 2 - 5

1.2.

3.

4.

M0*it0r a,t0r r#si,0 -i*,u*a*M0*it0r a,t0r r#si,0 "ari $#ri-a,u

M#*#ma*,a* strat#i ,0*tr0- a,t0r r#si,0

M0"ii,asi a'a hi"u$ u*tu, m#*ura*i r#si,0

NI/ A P#*#aha* $#r"araha* ;-##"i* Pr#auti0*a"i 45 ,. S#t#-ah "i-a,u,a* $#m#ri,saa* "i"a$at,a* A 139 mmH NA

12 =m#*it SA 3740/ %%A 22 =m#*it. S#t#-ah "i USC "i"a$at,a* atu "#*a*

u,ura* 1mm = 5mm . $asi#* "i "ia*0s# K0-#-itiasis.

.1. P&n%+a7!anaa* A Kar'a)ati

P#*"i"i,a* A SM!

!-amat A Suraa'a

- M%S A 111212


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a*"a Fita-A SA 3740/ a=i--a NA 12 =m#*it A 139 mmH %%A 22

=m#*it

0"' S'st#m

a. 1

Hi"u* A ti"a, t#r"a$at P/H

rah#a A ti"a, a"a ,#-ai*a*

Da"a A ti"a, a"a ,#-ai*a*

#*tu, A sim#tris

C#ra,a* A Sim#tris ti"a, a"a *'#ri "a"a *aas $#*"#, "a* "a*,a-

Suara *aas A :#si,u-#r

atu, A

S$utum A

/'a*0sis A

r#,u#*si *aas A 22 =m#*it

#r$asa* O2 *asa- 2 -$m

. 2


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P#*-ihata*A "*

P#raaa*A "*

". 4

Pr0"u,si Uri*# A 1 hari

(ar*a Uri*#A ,u*i* #-a$ s#$#rti t#h

Ca*ua* saat ,#*i*A

#. 5

Mu-utA #rsih ii -#*,a$ mu,0sa iir -#ma

#*0r0,a* ti"a, a"a sa,it m#*#-a*

!"0m#*A PA *'#ri ,ar#*a i*ta,# -#ma, m#*i*,at

A hi-a* timu- t#rus m#*#rus

%A a"0m#* ,a*a* atas "a$at m#*'#ar ,# $u*u* atau

ahu ,a*a*

SA s#"a*#rat

A ma-am hari

%#tumA "*


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36

atas m#*>a-ar ,# $u*u* atau ahu

,a*a* *'#ri "irasa,a* hi-a* timu-"#*a* s,a-a 5 "a* $a-i* $arah t#r>a"i

$a"a ma-am hari

DO A

$asi#* tam$a, m#*'#ri*ai ,#sa,ita*

a*"a Fita-A NA 12 =m#*it A 139

mmH %%A 22 =m#*it

USCA tam$a, atu "#*a* u,ura* 1

mm = 5 mm

2 DS A

$asi#* m#*ata,a* mua- mu*tah

$#rut ,#mu*

DO A

SM%SA 5 ,

s#,ara*A 45 ,

Mua- mu*tah K#ti"a,

s#ima*a*

*utrisiA ,ura*

"ari ,#utuha*

tuuh

3 DS APasi#* m#*ata,a* ,u-it*'a ata-

DO A

,u-it >au*"i# ,#ri* s-#ra ,u*i*

I,t#rus %#si,0,#rusa,a*

i*t#ritas ,u-it

.2. D!a%no#a K&(&'a:atan

1. N'#ri a,ut " $r0s#s $#*'a,it a"a*'a atu "a* i*#,si

2. K#ti"a,s#ima*a* *utrisiA ,ura* "ari ,#utuha* tuuh " mu*tah


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37

4.

5.

P0sisi *'ama*

L#:#- #*#riK#t#ra*a* A

1. i"a, $#r*ah "* 4. S#ri* "*

2. ara* "* 5. S#-a-u "*

3. Ka"a* "*

NI/ A Ma*a#m#* *'#ri

!,ti:itas A

1. Os#r:asi s,a-a *'#ri

6. #ri,a* a*a-#ti, "a* a*ti,0-i*#ri, ,a>i ,###,tia* ti*"a,a* $#r#"a

*'#ri

7. Hi*"ari m0ri* 'a* "a$at m#*'#a,a* s$asm# s$i*t#r O""i "a*

m#*i*,at,a* ,#ti"a,*'ama*a*

8. P#rtaha*,a* tirah ari* "a-am $0sisi *'ama* A iasa*'a ,#$a-a t#m$at

ti"ur "iti*i,a* 345 "#ra>at u*tu, m#*i*,at,a* u*si $#r*a$asa*


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u>ua* A Pasi#* mam$u m#*a$ai status *utrisi A i*ta,# ma,a*a*

"a* mi*uma* 'a* a"#,uat s#t#-ah "i-a,u,a* ti*"a,a* ,#$#ra)ata*.....hari

$#ra)ata*.

Krit#ria hasi- A

No. In"!+ato' 1 2 - 5

1.

2.

3.

4.

I*ta,# ma,a*a* $#r 0ra-

I*ta,# aira* $#r 0ra-

I*ta,# *utrisi $ar#*t#ra-

I*ta,# *utrisi $#r NC

NI/ A Ma*a#m#* *utrisi

!,ti:itas A

1. K0-a0rasi,a* "#*a* "0,t#r u*tu, m#mu-ai "i#t air >#r*ih 'a*

"i-a*>ut,a* "i#t -u*a, r#*"ah -#ma, u*tu, m#*ura*i stimu-asi

,a*"u* #m$#"u "a* *'#ri 'a* "itimu-,a* s#rta ,#mu*,i*a*

,amuh ,#ma-i

2. La,u,a* $#*hitu*a* ,a-0ri s#tia$ ,a-i s#-#sai ma,a* u*tu, m#*,a>i


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Faktor predisposisi:

Jenis kelamin / Usia / Berat badan / Maknan / Aktivitas Fisik / Multipara / Esterogen

kristalisasi/ presipitasi

olesterol

Cholesistiti

s

!angguanabsorbsi vit. A"E

#bstruksi andung

Empedu

Cholelitiasis

MK: ketidakseimbangankurang dari pemenuhan

nutrisi

Mual munta$

"istensiantong

empedu

!eta$ empedu tdk

diba%a ke

duodenum

!angguanpembekuan dara$

"inding kartilago

kosta &'1( tertekan

Menekan

!aster

"iba%a ke gin)al

Menu)u ulit *Mukosa P#-#$asa* h0rm0*

$r0sta-a*"i* ra"i,i*i*

S#r0t0*i*histami*

+roses

+eradangan

"iserap ole$

dara$

MK :Hipertermia

MK :Nyeri Akut

Urtikaria/pruritis

MK : ResikoKerusakan

Integritas Kulit

ikterus

Ekskresi Urine

Ber%arna gelap

,la- olored

Feses tidak di%arnai

pigmen empedu

-eri 00 saat

respirasi dalam

MK : Resiko

Perdarahan

MK : Kurang

Pengetahuan

erkresi

kolesterol -ang

berlebi$

supersaturasi

empedu

+enurunanAsam Empedu

Mal absorbsigaram empedu *

esitin

3eseksi ilium -g

luas

ukleasi

$olesterol

"is4ungsi

kandung Empedu

+rotein

Fos4olipase dan

Musin

n4eksi bakteri pada

saluran empedu

Bilirubin tak

terkun)ugasi

Mendekon)ugasikan

bilirubin dalam empedu

C-u,0r0*i"as#

Anemi $emolitik

alsium bilirubinat

batu pigmen murni

Kolelitiasis Kel. 7

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