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Asuhan Keperawatan Pasien dengan Batu Saluran Kemih (Urolitiasis)

A. Nyeri berhubungan dengan cedera jaringan sekunder terhadap batu ginjal dan spasme otot polos (Engram, 1998).

Intervensi

Tujuan :
Mendemonstrasikan rasa nyeri hilang

Kriteria hasil :
Tidak ada nyeri, ekspresi wajah rileks, tak ada mengerang dan perilaku melindungi bagian yang nyeri, frekwensi nadi 60-100 kali/menit, frekwensi nafas 12-24 kali/menit

Intervensi

  • Kaji dan catat lokasi, intensitas (skala 0-10) dan penyebarannya. Perhatikan tanda-tanda verbal : tekanan darah, nadi, gelisah, merintih.
  • Jelaskan penyebab nyeri dan pentingnya melaporkan ke staf terhadap perubahan kejadian/karakteristik nyeri.
  • Berikan tindakan untuk meningkatkan kenyamanan seperti pijatan punggung, lingkungan nyaman, istirahat.
  • Bantu atau dorong penggunaan nafas berfokus, bimbingan imajinasi dan aktifitas terapeutik.
  • Dorong/bantu dengan ambulasi sesuai indikasi dan tingkatkan pemasukan cairan sedikitnya 3-4 l/hari dalam toleransi jantung.
  • Kolaborasi, berikan obat sesuai indikasi :
    • narkotik
    • antispasmmodik
    • kortikosteroid
  • Berikan kompres hangat pada punggung.


B. Perubahan pola eliminasi urine sehubungan dengan obstruksi mekanik, inflamasi (Doenges, 1999)

Intervensi

Tujuan :
Klien berkemih dengan jumlah normal dan pola biasa atau tidak ada gangguan.

Kriteria hasil :
Jumlah urine 1500 ml/24 jam dan pola biasa, tidak ada distensi kandung kemih dan oedema.

Rencana tindakan

  • Monitor pemasukan dan pengeluaran serta karakteristik urine
  • Tentukan pola berkemih normal klien dan perhatikan variasi.
  • Dorong klien untuk meningkatkan pemasukan cairan.
  • Periksa semua urine, catat adanya keluaran batu dan kirim ke laboratorium untuk analisa.
  • Selidiki keluhan kandung kemih penuh : palpasi untuk distensi suprapubik. Perhatikan penurunan keluaran urine, adanya edema periorbital/tergantung.
  • Observasi perubahan status mental, perilaku atau tingkat kesadaran.
  • Awasi pemeriksaan laboratorium, contoh elektrolit, BUN kreatinin.
  • Ambil urine untuk kultur dan sensitivitas.
  • Berikan obat sesuai indikasi, contoh :
    • asetazolamid, alupurinol
    • HCT, klortaridon
    • amonium klorida : kalium fosfat/natrium fosfat
    • agen antigout
    • antibiotik
    • natrium bikarbonat
    • asam askorbat
  • Perhatikan patensi kateter tak menetap, bila menggunakan.
  • Irigasi dengan asam atau larutan alkali sesuai indikasi

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