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Asuhan Keperawatan Pasien Hernia

PENGKAJIAN
  1. Data Umum
    • Aktivitas atau istirahat
      Riwayat Pekerjaan
      Mengangkat beban berat, duduk, mengemudi dalam waktu lama, membutuhkan papan matras untuk tidur, penurunanrentang gerak, tidak mampu melakukan aktivitas yang biasa, atrofi otot gangguan dalam berjalan.

    • Eliminasi
      Kontipasi, obstipasi, adanya inkontinesia atau retensi urin.

    • Neurosensori
      Kesemutan, Kekakuan, kelemahan tangan atau kaki, penurunan refleks tendon dalam, nyeri tekan atau abdomen.

    • Pencernaan
      Bising usus, muntah, nyeri abdomen.

    • Kenyamanan
      Nyeri seperti ditusuk- tusuk, fleksi pada kaki, keterbatasan mobilisasi.
    • Kaji gaya hidup monoton atau hiperaktif.

  2. Pemeriksaan fisik
    • Inspeksi
      Mengkaji tingkat kesadaran, perhatikan adanya bengkak; ada atau tidak adanya benjolan

    • Palpasi
      Tugor kulit, palpasi terhadap nyeri dan massa

    • Auskultasi
      Bising usus, bunyi nafas, bunyijantung
    • Perkusi
      kembung

  3. Pemeriksaanpenunjang
    • Pemeriksaan darah koagulasi
    • Pemeriksaan urine
    • EKG


DIAGNOSA KEPERAWATAN
Diagnosa Keperawatan yang muncul pada klien dengan gangguan system pencernaan ; Hernia yaitu :
  1. Pre Operasi
    • Cemas berhubungan dengan tindakan operasi

  2. Post Operasi
    • Gangguan rasa nyaman : nyeri berhubungan dengan pembedahan herniatomy
    • Keterbatasan aktifitas barhubungan dengan kelemahan fisik
    • Defisit volume cairan berhubungan dengan pembedahan
    • Resti infeksi berhubungan dengan insisi pembedahan
    • Gangguan nutrisi kurang dari kebutuhan tubuh
    • Gangguan eliminasi fekal : Konsipasi berhubungan dengan penurunan aktifitas fisik
    • Kurang pengetahuan berhubungan dengan kurang informasi


INTERVENSI

Intervensi pada pre operasi yaitu jelaskan apa yang terjadi selama priode pasca operasi termasuk alasan puasa dan obat-obatan, ajarkan klien untuk nafas dalam dan membebat bagian yang dibedah ketika batuk, biarkan klien dan keluarga mengungkapkan perasaan tentang pengalaman pembedahaan. Sedangkan tahap pasca operasi pantau tanda-tanda vital kaji intensitas nyeri, lokasi dan skala nyeri, berikan analgenik sesuai indikasi, ganti balutan sesuai aturan dengan penggunaan tehnik aseptic dan anti septic, Bantu klien untuk melakukan gerak aktif dan pasif, kaji tanda-tanda infeksi seperti merah, panas, bengkak, nyeri dan penurunan fungsi, jelaskan proses penyakit serta pembatasan aktifitas yang berat-berat.



EVALUASI
Hasil yang diharapkan pada pasien hernia, yaitu:
  1. Cemas teratasi
  2. Nyeri berkurang sampai hilang
  3. Resti infeksi tidak terjadi
  4. Gangguan nutrisi teratasi
  5. Defisit cairan teratasi
  6. Keterbatasan aktifitas teratasi
  7. Kurang pengetahuan teratasi.
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