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Asuhan Keperawatan Pasien Dengan Inkontinensia Urine

Askep Klien Inkontinesia Urine


Pengertian

Dalam pengkajian ditanyakan kapan inkontinensia urine mulai muncul dan hal-hal yang berhubungan dengan gejala inkontinensia :
  • Berapa kali inkontinensia terjadi ?
  • Apakah ada kemerahan, lecet, bengkak pada daerah perineal ?
  • Apakah klien mengalami obesitas ?
  • Apakah urine menetes diantara waktu BAK, jika ada berapa banyak ?
  • Apakah inkontinensia terjadi pada saat-saat yang bisa diperkirakan seperti pada saat batuk, bersin tertawa dan mengangkat benda-benda berat ?
  • Apakah klien menyadari atau merasakan keinginan akan BAK sebelum inkontinensia terjadi ?
  • Berapa lama klien mempunyai kesulitan dalam BAK / inkontinensia urine ?
  • Apakah klien merasakan kandung kemih terasa penuh ?
  • Apakah klien mengalami nyeri saat berkemih ?
  • Apakah masalah ini bertambah parah ?
  • Bagaimana cara klien mengatasi inkontinensia ?

Pemeriksaan Fisik
  • Inspeksi
    Adanya kemerahan, iritasi / lecet dan bengkak pada daerah perineal.
    Adanya benjolan atau tumor spinal cord
    Adanya obesitas atau kurang gerak

  • Palpasi
    Adanya distensi kandung kemih atau nyeri tekan
    Teraba benjolan tumor daerah spinal cord

  • Perkusi
    Terdengar suara redup pada daerah kandung kemih.

Diagnosa Keperawatan
  • Kecemasan
  • Gangguan bodi image
  • Defisit pengetahuan
  • Kelemahan ( kurang aktivitas )
  • Gangguan Harga Diri
  • Gangguan Integritas Kulit

Rencana Tindakan
  • Menjaga kebersihan kulit, kulit tetap dalam keadaan kering, ganti sprei atau pakaian bila basah.
  • Anjurkan klien untuk latihan bladder training
  • Anjurkan pemasukkan cairan 2-2,5 liter / hari jika tidak ada kontra indikasi.
  • Anjurkan klien untuk latihan perineal atau kegel’s exercise untuk membantu menguatkan kontrol muskuler ( jika di indikasikan )
    Latihan ini dapat dengan berbaring, duduk atau berdiri
    • Kontraksikan otot perineal untuk menghentikan pengeluaran urine
    • Kontraksi dipertahankan selama 5-10 detik dan kemudian mengendorkan atau lepaskan
    • Ualngi sampai 10 kali, 3-4 x / hari
  • Cek obat-obat yang diminum ( narkotik, sedative, diuretik, antihistamin dan anti hipertensi ), mungkin berkaitan dengan inkontinensia.
  • Cek psikologis klien.


Daftar Pustaka

1. Charlene J. Reeves at all. Keperawatan Medikal Bedah, Jakarta : Salemba Medica, 2001.
2. Susan Martin Tucker at all. Patient Care Standarts Collaborative Planning & Nursing Interventions, Seventh Edition, St. Louis Baltimore Berlin : Mosby, 2000.
3. Luckmann’s, Suzanne E, Tatro. Care Principles and practise of Medical Surgical Nursing.
4. Christensen Kocknow. Adult Health Nursing, Third edition, St. Louis Baltimore, Boston : Mosby, 1999.
5. Susan Puderbangh, Susan W. Nursing Care Planning Guides, for Adult In Acute, Extended and Home Care Settings. WB. Saunders Company, 2001.
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