Nursing care process (askep) turp syndrome
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Transcript of Nursing care process (askep) turp syndrome
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ASKEP KLIEN DENGANTURP SYNDROME
Hendra Kurnia Rakhma, S.Kep., Ns
03 Maret 201003 Maret 2010
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Review BPH
Apa itu BPH? Cara pengukuran besar BPH? Terapi BPH?
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Transurethral resection of the prostate (TURP)
a procedure frequently used to treat moderate to severe BPH (Benign Prostate Hyperplasia or Obstruction).
removal of prostatic tissue by electro-cautery.
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Resectoscope
Light tower
Lens (30o)
Continuous flow irrigation
Bipolar Resctoscope loop
Rotatable Sheath
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Indications for TURP
Absolute
Recurrent Episodes of Urinary Retention
Recurrent UTI Gross Prostatic
Haematuria Bladder Stones Obstructive
Uropathy
Relative
Moderate to Severe Symptoms (IPSS) Bother / QoL Increasing PVR Low Flow rate
Failure of medical therapy / clinical progression
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Fungsi penggunaan cairan irigasi: distend the bladder clear the surgical site remove blood and resected tissue
Ideally the irrigation solution should be: Isotonic Electrically inert Non toxic Transparent inexpensive
Irrigation Solutions
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CAIRAN IRIGAN (yang pernah digunakan): Distilled water (H20 murni) air suling
Keuntungan: Transparent → Lapang pandang untuk area operasi >>
jelas Electrically inert
Kerugian: Extremely Hypotonic (osmolaritas serum <<) :
dapat menyebabkan intravascular hemolysis, shock and renal failure
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Glycine solution 5% (200 mOsm/L) di-metabolisme di hati menjadi amonia + oxalic
acids has direct toxic effects on the:
Heart: decrease of 17.5 % in cardiac output, arginine reversed myocardial depressionRetina: transient visual disturbance (blindness)
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Sorbitol solution (165 mOsm/L) di-metabolisme menjadi CO2 (70%) dan dextrose (30%) Adalah non toxic isomer dari mannitol Absorbsi dalam jumlah besar dapat memicu penambahan
komplikasi overload cairan menjadi hiperglikemi dan hiperkarbi
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Cytal solution (178 mOsm/L) Kombinasi dari sorbitol dan mannitol Bacterial containmination: kandungan gula dalam cairan
cytal menjadi medium yang sangat baik untuk bakteri Memperburuk hiperglikemia pada pasien diabetes
Mannitol solution The only isoosmolar irrigant (275 mOsm/L) Tidak di-metabolisme dan di-ekskresi secara utuh oleh
ginjal Absorbsi mannitol dalam jumlah besar akan membantu
cairan masuk kompartemen vaskuler dan memicu overload cairan yang cepat, odem paru dan gagal jantung
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Normal saline Hanya dapat digunakan pada bipolar resectoscope Eliminates TUR syndrome and obturator ‘kick’.
Di Indonesia, cairan yang paling sering digunakan dan harganya cukup murah adalah Normal Saline & H20 steril
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Keuntungan TURP
Menghindari insisi abdomen Lebih aman bagi pasien Metode pemulihan lebih singkat Angka morbiditas lebih rendah Menimbulkan nyeri yang sedikit
Brunner & Suddart, 2002
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Kerugian TURP
Membutuhkan dokter bedah yang ahli Obstruksi kambuhan trauma uretra dan
dapat terjadi striktur Perdarahan lama dapat terjadi
Brunner & Suddart, 2002
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TURP SYNDROME
TURP syndrome: constellation of signs and symptoms caused by the absorption of large volumes of isotonic irrigating fluids through prostatic veins or breaches in the prostatic capsule. (Saleem, 2008)
TRIAS TURP SYNDROME• Hypervolemia (Fluid Overload)• Dilutional hyponatremia • Hypo-osmolarity• Hiperammonemia (terjadi jika
menggunakan cairan glisin)
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Etiologi TURP syndromeDisebabkan oleh absorbsi masif dari cairan irigasi.
Absorbsi masif tergantung oleh:Proses TURP yang lama. absorbsi meningkat jika reseksi dilakukan lebih dari 90 menitTekanan intravaskuler me↑. krn tinggi bagian irigasi lebih dari 60 cm di atas lokasi pembedahanBanyak sinus prostat yang terbuka. semakin besar prostat yang direseksi, semakin banyak sinus prostat yang terbukaJenis cairan irigan yang digunakan.
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Manifestasi Klinis
Tanda dan gejala klinis awal: Restlessness, nyeri kepala, takipnea Dapat berlanjut menjadi respiratory distress,
hypoxia, pulmonary oedema, nausea, vomiting, confusion and coma
Tanda dan gejala dideteksi lebih dini pada pasien sadar
Pada pasien tidak sadar (dianestesi), tanda yang muncul hanya: takikardi dan hipertensiTitze, 2005
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Patofisiologi
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Komplikasi TURP Syndrome
Gagal napas Disebabkan oleh pertukaran gas yang tidak
adekuat karena odem paru Gagal jantung
Terjadinya hiponatremia aritmia jantung gagal jantung
Gagal ginjal akut Disebabkan oleh aliran darah ke ginjal me↓ akibat
curah jantung me↓ karena overload cairan
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Penatalaksanaan TURP Syndrome
Jika dideteksi saat intra operatif tindakan segera dihentikan dan pemberian cairan IV dihentikan
Air yang diabsorbsi harus dikeluarkan: Furosemid 40 mg iv
Bantu pernafasan dengan oksigen (nasal kanul atau masker, atau intubasi dan ventilasi jika diperlukan)
Simptomatik hiponatremia yang menyebabkan kelemahan sampai koma harus diatasi dengan cairan hipertonik (NaCl 3% = 0.513 mmol/ml) sampai gejala hilang
Titze, 2005
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Periksa BGA, serum sodium dan Hb Kelemahan dapat diatasi dengan dosis kecil midzolam
(2-4 mg), diazepam (3-5 mg) atau thiopental (50-100 mg)
Intubasi endotrakeal disarankan untuk mencegah aspirasi sampai status mental kembali normal
Jika odem paru dan hipotensi berlanjut invasif hemodinamik monitoring direkomendasikan sebagai petunjuk untuk penatalaksanaan farmakologis dan manajemen cairan
Titze, 2005
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Pencegahan TURP Syndrome
Membatasi waktu operasi <1 jam Melakukan operasi secara hati-hati untuk
meminimalkan sinus-sinus vena yang terbuka
Memposisikan irrigation bag maksimal 60 cm di atas area pembedahan
Menggunakan cairan irigan yang hangat
Imiak, 1999
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Asuhan Keperawatan Klien dgn Sindrom TURP Pengkajian Identitas
Terjadi akibat operasi TURP +50% laki-laki >60 thn, +80% laki-laki usia 80 thn. (Purnomo, 2003)
Keluhan Utama Sesak napas
Riwayat Kesehatan Pasien BPH dengan post operasi TURP
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Pemeriksaan Fisik
B1 breath: distress napas, odem paru, hipoksia, sianosis
B2 blood: hipertensi, aritmia B3 brain: pe↓an kesadaran, TIK↑, konfusi
sampai koma B4 bladder: gagal ginjal akut B5 bowel: mual, muntah B6 bone: gatal-gatal pada kulit
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Diagnosa Keperawatan
Kerusakan pertukaran gas b.d odem paru Kelebihan volume cairan b.d adanya
penyerapan cairan irigasi yang berlebihan Perubahan perfusi jaringan serebral b.d
peningkatan tekanan intrakranial
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Kerusakan pertukaran gas b.d odem paru
Tujuan Masalah kerusakan pertukaran gas teratasi
selama masa perawatan Kriteria Hasil SpO2 98-100% Analisa gas darah:
PaO2 80 – 100 mmHg PaCO2 35 – 45 mmHg pH 7,35 – 7,45
Tidak ada tanda distress napas: RR= 12 – 20 x/mnt, flaring nostril (-), tracheal tug (-),
intrekking (-)
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Intervensi Posisi semi fowler atau slide head up 30-45° Bebaskan jalan napas dengan kepala posisi
ekstensi Bantu pernafasan dengan oksigen (nasal kanul
atau masker, atau intubasi dan ventilasi jika diperlukan)
Pertahankan istirahat klien Kolaborasi pemberian furosemid Monitor evaluasi BGA, pulse oxymeter
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Kelebihan volume cairan adanya penyerapan cairan irigasi yang berlebihan Tujuan
Kelebihan volume cairan teratasi selama masa perawatan Kriteria Hasil
Odem paru (-), odem seluruh tubuh (-) Asites (-) Hasil lab elektrolit:
Na+ 135 – 145 mEq/L K+ 3,5 – 5,0 mEq/L
Hemodinamik CVP = 5 – 15 cmH20 Tanda vital: TD = 120/90 mmHg, nadi = 60 – 100 x/mnt
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Intervensi Restriksi cairan I=IWL Kolaborasi pemberian terapi diuretik Kolaborasi tindakan invasif hemodinamik
(pemasangan CVP) Atasi hiponatremi dengan cairan hipertonik (NaCl
3% = 0.513 mmol/ml) sampai gejala hilang Pantau tanda dan gejala hiponatremi Pantau TTV
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Perubahan perfusi jaringan serebral b.d peningkatan tekanan intrakranial Tujuan Masalah perubahan perfusi jaringan serebral
teratasi selama masa perawatan Kriteria Hasil Tidak ada tanda pe↑an TIK
Nyeri kepala, muntah proyektil, kaku kuduk, papil edema
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Intervensi Slide head up 30°-45° Cegah hal-hal yang dpt me↑kan TIK: batuk,
mengejan, posisi trendelenburg Monitor evaluasi adanya tanda-tanda TIK↑