ASKEP PADA PASIEN KANKER OVARIUMFiled under: Keperawatan Leave a comment March 24, 2012 ASKEP PADA PASIEN KANKER OVARIUM I. PENGERTIAN Kanker Indung telur atau Kanker ovarium adalah tumor ganas pada ovarium (indung telur) yang paling sering ditemukan pada wanita berusia 50 70 tahun. Kanker ovarium bisa menyebar ke bagian lain, panggul, dan perut melalui sistem getah bening dan melalui sistem pembuluh darah menyebar ke hati dan paru-paru. Kanker ovarium sangat sulit didiagnosa dan kemungkinan kanker ovarium ini merupakan awal dari banyak kanker primer. (Wingo, 1995) 0100090000035002020000006926010000001610000026060f002220574d464301000000000001 008d82000000000e00000000200000fc940100fcb40100010000006c00000000000000000000008 4010000e400000000000000000000007e2d0000c91a000020454d4600000100fcb401000c000000 01000000000000000000000000000000560500000003000099010000e600000000000000000000 0000000000a83d060070820300460000002c00000020000000454d462b014001001c0000001000 00000210c0db01000000600000006000000046000000c02a0000b42a0000454d462b224004000c 000000000000001e4009000c00000000000000244001000c000000000000003040020010000000 040000000000803f214007000c00000000000000084000050c2a0000002a00000210c0db010000 000000000000000000000000000000000001000000ffd8ffe000104a46494600010101004800480 000ffdb00430007050606060507060606080807090b120c0b0a0a0b1710110d121b171c1c1a171a 191d212a241d1f2820191a253225282c2d2f302f1d233438342e372a2e2f2effdb0043010808080b 0a0b160c0c162e1e1a1e2e2e2e2e2e2e2e2e2e2e2e2e2e2e2e2e2e2e2e2e2e2e2e2e2e2e2e2e2e2e2e 2e2e2e2e2e2e2e2e2e2e2e2e2e2e2e2e2e2e2effc200110800ac012403012200021101031101ffc40 01b00000203010101000000000000000000000005030406020107ffc4001901010101010101000 00000000000000000000102030405ffda000c03010002100310000001fa4000000670d11f2af674f aa1f2d686f8c1427d0cc2f46e4c37726d8c4f55b33097cd67bf3578badf7e6ac8db9f3a649b33e75e4 bf463e753d6fbd5acaf3000000000000042fb3cb918bbafcfd3a1bb243ac2f39e33abf2abe8bb521f5 67e63b56579a1e228d9a5234d7ba2cae5aafad5ae651f219799974935af6ea1bf4f28000000000000 66f499d5c8451cdcfd5a9e16b1b85f5a7a735cc5c8d4bec2268a0b2b2e6dd1b6b65839f6a965a2660 33659f91396bc54b2ea96166570dd4b6df980280000000000cee8b36b89b16bbe7e9f2550d22f236 6a2b8f49579bf4346cd1826beabb3ecb45cfa65d74d1ef9f376582cb1614e873b861acdf9f558d944 75f416e99cfa3e7005000002de27f0ae77e8c53334d2ae4d69770f651b94baa6b53df7788fcebc5b9 7a064cada97fce5e99dbc99f614d5e64b979ef3639df6b68b31ab43a2d2d683539d4dd394d7fd3e0b 4508a9a0bee12005649a40cedf660296c965cbe7f409f87ae8f7e9756fda93ef9f562bdb195b576639 f6a4bcbbce9e2bf354246da4ce330cee288b1c584bb55f69d9d736957cb135a26d4db7a7c4b20b15 ec918cc000000007885f235cfa9bf5f8fad65071cc45dc56538eeed8c6fcb9e4fe7ed56bb45ba9097b 8efcabf1657f3eb72ee59bde6cd2cb1ea2eb937765fad6b834cd5535f4f883cf40f3d00013b8aa2f93 be8b683469153aabd1e3baef7af33ae26eab657794acf1b72f328c71a75897cb751859c4eebbf1b88

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2. Tumor germinAL Tumor sel germinal berasal dari sel yang menghasilkan ovum atau telur, umumnya tumor germinal adalah jinak meskipun beberapa menjadi ganas, bentuk keganasan sel germinal terutama adalah teratoma, dysgerminoma dan tumor sinus endodermal. Insiden keganasan tumor germinal terjadi pada usia muda kadang dibawah usia 20 tahun, sebelum era kombinasi kemoterapi harapan hidup satu tahun kanker ovarium germinal stadium dini hanya mencapai 10 19% sekarang ini 90 % pasien kanker ovarium germinal dapat disembuhkan dengan fertilitas dapat dipertahankan. 3. Tumor stromal Tumor ovarium stromal berasal dari jaringan penyokong ovarium yang memproduksi hormon estrogen dan progesteron, jenis tumor ini jarang ditemukan, bentuk yang didapat berupa tumor theca dan tumor sel sartoli-leydig termasuk kanker dengan derajat keganasan yang rendah. Stadium kanker ovarium primer menurut FIGO (Federation InternationalofGinecologies and Obstetricians ) 1987, adalah : STADIUM I > pertumbuhan terbatas pada ovarium 1) Stadium 1a : pertumbuhan terbatas pada suatu ovarium, tidak ada asietas yang berisi sel ganas, tidak ada pertumbuhan di permukaan luar, kapsul utuh. 2) Stadium 1b : pertumbuhan terbatas pada kedua ovarium, tidak asietas, berisi sel ganas, tidak ada tumor di permukaan luar, kapsul intak. 3) Stadium 1c : tumor dengan stadium 1a dan 1b tetapi ada tumor dipermukaan luar atau kedua ovarium atau kapsul pecah atau dengan asietas berisi sel ganas atau dengan bilasan peritoneum positif. STADIUM II > Pertumbuhan pada satu atau dua ovarium dengan perluasan ke panggul 1) Stadium 2a : perluasan atau metastasis ke uterus dan atau tuba 2) Stadium 2b : perluasan jaringan pelvis lainnya 3) Stadium 2c : tumor stadium 2a dan 2b tetapi pada tumor dengan permukaan satu atau kedua ovarium, kapsul pecah atau dengan asitas yang mengandung sel ganas dengan bilasan peritoneum positif. STADIUM III > tomor mengenai satu atau kedua ovarium dengan implant di peritoneum di luar pelvis dan atau retroperitoneal positif. Tumor terbatas dalam pelvis kecil tetapi sel histologi terbukti meluas ke usus besar atau omentum 1) Stadium 3a : tumor terbatas di pelvis kecil dengan kelenjar getah bening negatif tetapi secara histologi dan dikonfirmasi secara mikroskopis terdapat adanya pertumbuhan (seeding) dipermukaan peritoneum abdominal. 2) Stadium 3b : tumor mengenai satu atau kedua ovarium dengan implant dipermukaan peritoneum dan terbukti secara mikroskopis, diameter melebihi 2 cm, dan kelenjar getah bening negativ. 3) Stadium 3c : implant di abdoment dengan diameter > 2 cm dan atau kelenjar getah bening retroperitoneal atau inguinal positif.

STADIUM IV > pertumbuhan mengenai satu atau kedua ovarium dengan metastasis jauh. Bila efusi pleura dan hasil sitologinya positif dalam stadium 4, begitu juga metastasis ke permukaan liver. Derajat keganasan kanker ovarium : Derajat 1 : differensiasi baik Derajat 2 : differensiasi sedang Derajat 3 : differensiasi buruk Dengan derajat differensiasi semakin rendah pertumbuhan dan prognosis akan lebih baik. II. ETIOLOGI Penyebab kanker ovarium belum diketahui secara pasti. Akan tetapi banyak teori yang menjelaskan tentang etiologi kanker ovarium, adapun penyebab dari kanker ovarium yaitu: 1. Hipotesis incessant ovulation Teori menyatakan bahwa terjadi kerusakan pada sel-sel epitel ovarium untuk penyembuhan luka pada saat terjadi ovulasi. Proses penyembuhan sel-sel epitel yang terganggu dapat menimbulkan proses transformasi menjadi sel-sel tumor. 2. Hipotesis androgen Androgen mempunyai peran penting dalam terbentuknya kanker ovarium. Hal ini didasarkan pada hasil percobaan bahwa epitel ovarium mengandung reseptor androgen. Dalam percobaan in-vitro, androgen dapat menstimulasi pertumbuhan epitel ovarium normal dan sel-sel kanker ovarium. Faktor Resiko : 1. Diet tinggi lemak 2. merokok 3. alkohol 4. penggunaan bedak talk perineal 5. riwayat kanker payudara, kolon, atau endometrium 6. riwayat keluarga dengan kanker payudara atau ovarium 7. nulipara 8. infertilitas 9. menstruasi dini 10. tidak pernah melahirkan III. PATOFISIOLOGI Kanker ovarium disebabkan oleh zat-zat karsinogenik sehingga terjadi tumor primer dimana akan terjadi infiltrasi di sekitar jaringan dan akan terjadi implantasi. Dimana implantasi ini merupakan cirri khas dari tumor ganas ovarium. Gejala yang terjadi pada kanker ovarium adalah gejala samar dan ascites. Ascites adalah kelebihan volume cairan di rongga perut, sedangkan gejala samarnya yaitu : perut sebah, makan sedikit tapi cepat kenyang, sering kembung, dan nafsu makan menurun. IV. MANIFESTASI KLINIS

Manifestasi klinis terutama berupa rasa tidak enak perut bawah atau tenesmus, pada stadium awal dapat timbul asites; dengan cepat kanker tumbuh melampaui kavum pelvis hingga ke abdomen hingga teraba massa; haid tidak teratur, dapat timbul perdarahan per vaginam Tanda & Gejala pada pasien Kanker Ovarium,, Gejala umum bervariasi dan tidak spesifik. Pada stadium awal berupa : 1. haid tidak teratur 2. ketegangan menstrual yang terus meningkat 3. menoragia 4. nyeri tekan pada payudara 5. menopause dini 6. rasa tidak nyaman pada abdomen 7. dispepsia 8. tekanan pada pelvis 9. sering berkemih 10. flatulenes 11. rasa begah setelah makan makanan kecil 12. lingkar abdomen yang terus meningkat V. PEMERIKSAAN DIAGNOSTIK 1. USG dengan Doppler untuk menentukan arus darah 2. Jika diperlukan, pemeriksaan CT-Scan/ MRI 3. Pemeriksaan tumor marker seperti Ca-125 dan Ca-724, beta HCG dan alfafetoprotein Semua pemeriksaan diatas belum bisa memastikan diagnosis kanker ovarium, akan tetapi hanya sebagai pegangan untuk melakukan tindakan operasi. VI. PENATALAKSANAAN MEDIS Sebagian besar kanker ovarium memerlukan pengobatan dengan kemoterapi. Hanya kanker ovarium stadium awal saja (stadium 1a dan 1b dengan derajat diferensiasi sel yang baik/sedang) yang tidak memerlukan kombinasi pengobatan. Kemoterapi diberikan sebanyak 6 seri dengan interval 3 4 minggu sekali dengan melakukan pemantauan terhadap efeh samping kemoterapi secara berkala terhadap sumsum tulang, fungsi hati, fungsi ginjal, sistem saluran cerna, sistem saluran cerna, sistem saraf dan sistem kardiovaskuler. Metode terapi utama YAITU: 1. Kemoterapi dengan pemanasan intraperitoneal: melalui insisi perkutan dimasukkan dua tabung silicon intraperitoneal, satu diletakkan di permukaan hati subdiafragma, satu lagi di resesus posterior kavum pelvis, ujungnya difiksasi di dinding abdomen. Obat yang diinfuskan biasanya FU, DDP, CTX dll. di dalam 3000-4000cc larutan garam faal. Sebelumnya larutan itu dipanaskan hingga 42C, dan upayakan temperatur itu dipertahankan. Lalu melalui satu tabung silicon dialirkan ke rongga abdomen, setelah 8-12 jam larutan dikeluarkan lewat tabung yang lainnya. Kecepatan pemberian adalah 500cc per jam. Setiap minggu dilakukan 1-2 kali. Efek buruknya berupa sakit perut, untuk itu dapat serentak diberikan lidokain intraperitoneal.

2. Imunoterapi intraperitoneal: masukkan tabung ke rongga pelvis, abdomen, suntikkan obat kemoterapi, 1-2 kali per minggu, serentak disuntikkan imunomodulator, umumnya digunakan vaksen kuman Serratia marcescen(S311), 1cc per kali. Pasca injeksi dapat timbul demam yang mencapai 39oC, 2-3 jam kemudian reda spontan. Demam pertanda respons imun bekerja, tidak akan berdampak buruk. 3. Krioablasi argon-helium: terhadap massa ovarium, tidak peduli itu lesi primer atau metastasis rongga pelvis dan dinding abdomen, dapat memakai krioablasi argon-helium. Metode ini setara dengan operasi debulking, rudapaksa bagi pasien jauh lebih keci dibandingkan operasi. 4. Terapi intra-arteri: melalui arteri femoralis dimasukkan kateter hingga mencapai arteri ovarial, suntikkan emulsi campuran kemoterapi (misal DDP) dan lipiodol. Jepang melaporkan terapi dengan cara ini, setelah 1 bulan massa ovarium menyusut rata-rata 49%. Kami sering mengombinasikan cara ini dengan krioablasi argon-helium. Seorang pasien dari kota Shenyang di RRC, usia 56 tahun, kavum pelvis penuh dengan tumor disertai asites, setelah terapi intraarteri dan krioablasi argon-helium, lesi lenyap total, hingga kini 18 bulan tidak tampak kekambuhan. VII. KOMPLIKASI Akibat radiasi atau penyinaran maka timbul komplikasi: indung telur mati terkena radiasi akibatnya hormone pun mati,padahal hormone diperlukan untuk gairah seksual dan haid juga mencegah osteoporosis, komplikasi lainnya antara lain luka bakar pada dubur,terjadi diare/perdarahan terus,jika tidak demikian dubur harus diangkat sebagai gantinya akan dibuatkan dubur baru lewat perut. VIII. PENCEGAHAN Cara termudah untuk mengurangi kemungkinan kanker ovarium adalah; 1. Mengambil kontrasepsi oral atau pil KB. 2. Mengikat saluran tuba. 3. Beberapa studi telah menunjukkan bahwa histerektomi juga akan mengurangi risiko kanker ovarium. Namun, tidak dianjurkan untuk memiliki prosedur ini dilakukan kecuali jika itu adalah alasan medis yang baik untuk melakukannya. Jika seorang wanita telah melalui menopause atau mendekati menopause maka mungkin ide yang baik untuk memiliki ovarium diangkat melalui histerektomi. ASUHAN KEPERAWATAN I. PENGKAJIAN Data diri klien Data biologis/fisiologis > keluhan utama, riwayat keluhan utama Riwayat kesehatan masa lalu Riwayat kesehatan keluarga Riwayat reproduksi > siklus haid, durasi haid Riwayat obstetric > kehamilan, persalinan, nifas, hamil

Pemeriksaan fisik Data psikologis/sosiologis> reaksi emosional setelah penyakit diketahui II. DIAGNOSA KEPERAWATAN 1. Nyeri akut b.d agen cidera biologi 2. Perubahan citra tubuh dan harga diri b.d perubahan dalam penampilan fungsi dan peran 3. Resiko tinggi terhadap disfungsi seksual b.d perubahan struktur atau fungsi tubuh, perubahan kadar hormone 4. Ansietas b.d perubahan status kesehatan 5. Kurang pengetahuan/kurang informasi b.d kondisi,prognosis dan pengobatan III. PERENCANAAN Diagnosa 1 : Nyeri akut b.d agen cidera biologi Tujuan : Klien merasa reda dari nyeri dan ketidaknyamanan yang ditimbulkan Kriteria Hasil : Nyeri berkurang atau skala nyeri berkurang 1-3, dan pasien tidak meringis Intervensi : Kaji karakteristik nyeri : lokasi, kualitas, frekuensi R/:membantu mengevaluasi derajat ketidaknyamanan. Kaji faktor lain yang menunjang nyeri, keletihan, marah pasien. R/: mengevaluasi factor factor yang yang dapat meningkatkan persepsi akan intensitas nyerinya. Kolaborasi dengan tim medis dalam memberi obat analgesic R/: menurunkan nyeri, meningkatkan kenyamanan. Jelaskan kegunaan analgetik dan cara-cara untuk mengurangi efek samping. R/: agar pasien mengetahui mengenai penggunaan dan efek samping dari analgetik. Ajarkan klien strategi baru untuk meredakan nyeri dan ketidaknyamanan: imajinasi, relaksasi, stimulasi kutan. R/: membantu pasien untuk istirahat lebih efektif dan memfokuskan kembali perhatian, sehingga menurunkan nyeri dan ketidaknyamanan. Diagnosa 2 : Perubahan citra tubuh dan harga diri b.d perubahan dalam penampilan fungsi dan peran Tujuan : Klien dapat memperbaiki persepsi citra tubuh dan harga dirinya. Kriteria Hasil : - Klien dapat menerima status kesehatannya - Klien dapat menerapkan koping individu yang adaptif Intervensi : Kaji perasaan klien tentang citra tubuh dan tingkat harga diri R/: mengetahui respon pasien dalam penegakan diagnosa. Berikan dorongan untuk keikutsertaan kontinyu dalam aktifitas dan pembuatan keputusan R/: mempertahankan / membuka garis komunikasi

Berikan dorongan pada klien dan pasangannya untuk saling berbagi kekhawatiran tentang perubahan fungsi seksual dan menggali alternatif untuk ekspresi seksual yang lazim R/: menjelaskan keadaan yang terjadi dan memberi pengertian kepada pasangan serta mendiskusikan dalam pemenuhan kebutuhan seksual . Diagnosa 3 : Resiko tinggi terhadap disfungsi seksual b.d perubahan struktur atau fungsi tubuh, perubahan kadar hormon Tujuan : Mengidentifikasi kepuasan/ praktik seksual yang diterima dan beberapa alternatif cara mengekspresikan keinginan seksual Kriteria Hasil : - Klien menyatakan paham tentang perubahan struktur dan fungsi seksual. - Klien mampu memenuhi kebutuhan seksualnya sesuai dengan kemampuan Intervensi: Mendengarkan pernyataan klien dan pasangan R/: masalah seksual sering tersembunyi sebagai pernyataan humor dan/ atau ungkapan yang gamblang Diskusikan sensasi atau ketidaknyamanan fisik, perubahan pada respons individu R/: nyeri vagina dapat nyata menyertai prosedur vagina atau kehilanagn sensori dapat terjadi sehubungan dengan trauma bedah. Meskipun kehilangan sensori biasanya sementara, ini dapat dialami selama beberapa minggu atau bulan untu kembali baik. Kaji informasi klien dan pasangan tentang anatomi/ fungsi seksual dan pengaruh prosedur pembedahan R/: menunjukan kesalahan informasi/konsep yang mempenagruhi pengambilan keputusan. Harapan negative sehubungan dengan hasil yang buruk. Identifikasi faktor budaya/nilai budaya R/: dapat mempengaruhi kembalinya kepuasan hubungan seksual. Dorong klien untuk menyadari atau menerima tahap berduka R/: kehilangan bagian tubuh, hilangnya bagian tubuh, dan menerima kehilangan yang memebutuhkan penerimaan sehingga pasien dapat membuat rencana untuk masa depan. Dorong klien untuk berbagi pikiran/masalah dengan orang terdekatnya R/: komunikasi terbuka dapat mengidentifikasi area penyesuaian / masalah dan meningkatkan diskusi dan resolusi. Berikan solusi masalah terhadap masalah potensial. ex : menunda koitus seksual saat kelelahan R/: membantu pasien kembali pada hasrat / kepuasan aktivitas seksual. Diagnose 4 : Ansietas b.d perubahan status kesehatan Tujuan : Menyatakan kesadaran terhadap perasaan dan rasa cenas yang sedang dihadapinya. Kriteria hasil: - Pasien tidak merasa gelisah, - Pasien tanpak rileks Intervensi:

Orientasikan klien pada lingkungan yang baru R/: membantu mengurani ansietas dan meningkatkan keamanan Beritahu klien tentang perjalanan penyakitnya R/: memberikan informassi kepada klien tentang penyakitnya dan mengurangi ansietas Beritahu klien tentang tindakan pengobatan yang akan dilakukan R/: mengurangi ansietas klien Diagnosa 5 : Kurang pengetahuan/kurang informasi b.d kondisi,prognosis dan pengobatan Tujuan : klien mengetahui tentang kondisi dan prognosis tentang penyakitnya Kriteria hasil: - Klien terlihat tenang - Klien mengerti tentang kondisinya Intervensi: Kaji informasi tentang kondisi individu,prognosis dan pengobatan R/: meningkatkan pemahaman perawat tentang kondisi klien Beritahu klien tentang perjalanan penyakitnya serta pengobatan yang akan dilalukan R/: memberikan informasi kepada klien tentang penyakitnya IV. IMPLEMENTASI Implementasi merupakan pelaksanaan dari rencana yang telah disusun. V. EVALUASI 1. Klien merasa reda dari nyeri dan ketidaknyamanan yang ditimbulkan 2. Klien dapat memperbaiki persepsi citra tubuh dan harga dirinya. 3. Mengidentifikasi kepuasan/ praktik seksual yang diterima dan beberapa alternatif cara mengekspresikan keinginan seksual 4. Menyatakan kesadaran terhadap perasaan dan rasa cemas yang sedang dihadapinya. 5. Klien mengetahui tentang kondisi dan prognosis tentang penyakitnya. WOC

Ascites

Definisi AscitesAscites adalah akumulasi dari cairan (biasanya cairan serous yang adalah cairan kuning pucat dan bening) dalam rongga perut (peritoneal). Rongga perut berlokasi dibawah rongga dada, dipisahkan darinya oleh diaphragm. Cairan ascitic dapat mempunyai banyak sumber-sumber

seperti penyakit hati, kanker-kanker, gagal jantung congestif, atau gagal ginjal.

Penyebab AscitesPenyabab yang paling umum dari ascites adalah penyakit hati yang telah lanjut atau cirrhosis. Kira-kira 80% dari kasus-kasus ascites diperkirakan disebabkan oleh cirrhosis. Meskipun mekanisme yang tepat dari perkembangan tidak dimengerti sepenuhnya, kebanyakan teori-teori menyarankan portal hypertension (tekanan yang meningkat adalam aliran darah hati) sebagai penyumbang utama. Asas dasarnya adalah serupa pada pembentukan dari edema ditempat lain di tubuh yang disebabkan oleh ketidakseimbangan tekanan antara sirkulasi dalam (sistim tekanan tinggi) dan luar, dalam kasus ini, rongga perut (ruang tekanan rendah). Kenaikan dalam tekanan darah portal dan pengurangan dalam albumin (protein yang diangkut dalam darah) mungkin bertangung jawab dalam pembentukan gradien tekanan dan berakibat pada ascites perut. Faktr-faktor lain yang mugkin berkontribusi pada ascites adalah penahanan garam dan air. Volume darah yang bersirkulasi mungkin dirasakan rendah oleh sensor-sensor dalam ginjalginjal karena pembentukan dari ascites mungkin menghabiskan beberapa volume dari darah. Ini memberi sinyal pada ginjal-ginjal untuk menyerap kembali lebih banyak garam dan air untuk mengkompensasi volume yang hilang. Beberapa penyebab-penyebab lain dari ascites berhubungan dengan gradien tekanan yang meningkat adalah gagal jantung kongestif dan gagal ginjal yang telah lanjut yang disebabkan oleh penahanan cairan keseluruhan dalam tubuh. Pada kasus-kasus yang jarang, tekanan yang meningkat dalam sistim portal dapat disebabkan oleh rintangan internal atau eksternal dari pembuluh portal, berakibat pada portal hypertension tanpa cirrhosis. Contoh-contoh dari ini dapat adalah massa (atau tumor) yang menekan pada pembuluh-pembuluh portal dari rongga perut bagian dalam atau pembentukan bekuan (gumpalan) darah dalam pembuluh portal yang menghalangi aliran normal dan menongkatkan tekanan dalam pembuluh (contoh, Budd-Chiari syndrome). Ada juga pembentukan ascites sebagai akibat dari kanker-kanker, yang disebut malignant ascites. Tipe-tipe ascites ini secara khas adalah manifestasi-manifestasi dari kanker-kanker yang telah lanjut dari organ-organ dalam rongga perut, seperti, kanker usus besar, kanker pankreas, kanker lambung, kanker payudara, lymphoma, kanker paru-paru, atau kanker indung telur. Pancreatic ascites dapat terlihat pada orang-orang dengan pancreatitis atau peradangan pankreas kronis. Penyebab yang paling umum dari pankreatitis kronis adalah penyalahgunaan alkohol yang berkepanjangan. Pancreatic ascites dapat juga disebabkan oleh pankreatitis akut serta trauma pada pankreas.