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ASUHAN KEPERAWATAN
KLIEN DENGAN CA COLON
By:
Group 6th(The Enterprenure Group!
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KOLON DAN REKTUM
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An"to#$ Ko%on
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An"to#$ Re&tu#
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'$$o%o$ Ko%on ) Re&tu#
'un$ Ko%on:"*or*$ "$r+ ,$t"#$n-"n e%e&tro%$t
Kontr"&$ &o%ore&t"%-$pen"ruh$ p%e&u"r". $ntr$n$/
Re&tu# nor#"%ny"&oon -"n &et$&"eeor"n *"nun
t$-ur -"n #"&"np"$ #en$#*u%&"n#ot$%$t" &o%on &$r$+.ee #e#"u&$
re&tu# -"n or"ntere*ut #er""$n$n -e.e&"$
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H$to%o$ Ko%on
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KANKER KOLOREKTAL
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KEGANASAN PERINGKAT KE01 DI USADI INDONESIA
KARSINO2A KOLON PERINGKAT KE03KARSINO2A REKTU2 PERINGKAT KE045KARSINO2A KOLO REKTAL PERINGKAT
KE06
INSIDEN PRIA SA2A DENGAN WANITA
(PUSAT DATA DAN IN'OR2ASI KE2ENTERIAN KESEHATAN RI+547!
EPIDE2IOLOGI
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De8n$$
K"n&er &o%ore&t"% #erup"&"n &"n&ery"n #enyer"n &o%on "t"u re&tu#9K"n&er $n$ u" -"p"t -$e*ut &"n&er
&o%on "t"u &"n&er re&t"%+ ter"ntun-$#"n" &"n&er tere*ut ter"-$9 K"n&er&o%on -"n &"n&er re&t"% er$n ter"-$
e/"r" *er"#""n &"ren" #e#puny"$/$r$0/$r$ y"n "#" (A#er$/"n C"n/erSo/$ety+ 54;!9
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Etiologi dan Faktor Risiko
Penye*"* ut"#" -"r$ &"n&er &o%ore&t"%*e%u# -$&et"hu$ e/"r" p"t$9
(S#e%t
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'"&torR$$&o
D"p"t-$u*"
h
D$et
A&t$,$t"'$$&O*e$t
"2ero&o
&
T$-"&-"p"t-$u*"h
U$"Po%$pKo%on
In="##"tory Bo>e%D$e"eGenet
$&
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K%"$8&"$ Po%$p Ko%on
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P"to8$o%o$
K"n&er p"-" &o%on -"n re&tu# -$">"%$-en"n "-"ny" r$>"y"t po%$p9 Po%$p#erup"&"n #"" -"r$ "r$n"n y"n
#enono% p"-" %u#en uu (S#e%t
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St"-$u#
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K%"$8&"$ K"n&er Ko%ore&t"%
(De,$t"+ et "%9+547!
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2"n$.et"$ K%$n$
Ke%uh"n y"n er$n&ont$p"$
Ke%uh"n &"%$*er .ee#ee/$%
Ke%uh"n o*tru&$
S$."t tu#orTu#*uh "nu%er -"n
&ontr$&t$n eh$n"#enye*"*&"n o*tru&$
K"r$n$#" &o%on &$r$
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K"r$no#" &o%on &"n"n
Nyer$ tu#pu%
Ter"*" #"" p"-"perut &"n"n *">"h Ane#$" Ser$n -$"re
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K"r$no#" Re/tu#
Ber"& -"r"h -"n%en-er
Ber"t *"-"n
#enurunTene#u
Ser$n -$-$"no"e*""$ he#orho$-
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Ko#p%$&"$
49 O*tru&$ uu p"r$"% "t"u %en&"p9
9 2et"t"e &e or"n e&$t"r+ #e%"%u$he#"toen+ %$#.oen -"npenye*"r"n %"nun9
19 He#orr"$9
;9 A*e9
79 Per$ton$t$ -"n "t"u ep$ -"p"t#en$#*u%&"n yo&
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PEMERIKSAAN
Pe#er$&""n '$$&
Pe#er$&""n
D$"not$
&
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Pe#er$&""n '$$&
49 Pe#er$&""n A*-o#en
9 Co%o& Du*ur
P"-" pe#er$&""n $n$ y"n h"ru-$n$%"$:
-. Ke"-""n tu#or
-.
2o*$%$t" tu#or-. E&ten$ pen"%"r"n
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Pe#er$&""n D$"not$&
49 En-o&op$
9 CT S/"n -"n 2RI
19 B"r$u# Ene#";9 CEA (C"r/$no E#*r$on$& Ant$en!
S/reen$n
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Pen"t"%"&"n""n
49 Pen"t"%"&"n""n #e-$
Ke#oter"p$ Ter"p$ r"-$"$
Ko#*$n"$
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9 Pen"t"%"&"n""n Be-"h
Ree&$ e#ent"%
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Ko%oto#$
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Pen"t"%"&"n""nKeper">"t"n
"9 2e#pert"h"n&"n e%$#$n"$ p"$en
*9 2e#pert"h"n&"n "t"u #en$n&"t&"n&eny"#"n"n
/9 2en$n&"t&"n to%er"n$ "&t$,$t"
-9 2e#*"ntu pe#*er$"n nutr$$ opt$#"%
e9 2e#pert"h"n&"n &ee$#*"n"n /"$r"n
-"n e%e&tro%$t.9 2e%"&u&"n per">"t"n &u%$t+ %u&" -"n
&o%oto#$ (p"/" *e-"h!
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KONSEP ASUHANKEPERAWATAN
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Pen&"$"n
I-ent$t" Ke%uh"n ut"#"
Nyer$ p"-" -"er"h "*-o#en "t"u
re&t"%+ &eu%$t"n -"%"# #e%"&u&"n*u"n "$r *e"r -"n per-"r"h"np"-" "nu9
R$>"y"t peny"&$t e&"r"n R$>"y"t peny"&$t -"hu%u
R$>"y"t peny"&$t &e%u"r"
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Pe#er$&""n '$$&
B1 Br!at"ing#
D"-" $#etr$+ t"&t$% .re#$tu &"n"n0&$r$ "#"+ ,e$&u%er+ RR 4605&"%$?#en$t+ t$-"& "-" /up$n h$-un+ t$-"& "-" penun""n ototpern"p""n t"#*"h"n9
B$ Blood#
TD 45?@5 ##H+ N"-$ 650@5 &"%$?#en$t+ n"-$ ter"*" &u"t+ "&r"% h"n"t+CRT -et$&9
B% Brain#
Co#po#ent$ -en"n GCS 47+ E; 7 26+ re"&$ pup$% $o&or 1?(&"n"n!+ 1? (&$r$!+ re=e& /"h"y" ?
B& Bladd!r#
're&uen$ BAK + >"rn" -"n pro-u&$ ur$n+ terp""n &"teter "p" t$-"&9
B' Bo(!l#
Bentu& perut ""& /e#*un+ per$t"%t$& per#en$t+ ter-"p"t &ont$p"$ ?-$"re+ *uny$ re-up ? onor+ -u%%ne+ "-"ny" nyer$ te&"n ? t$-"&9
B) Bon!#
E&tre#$t" "t" : Ke&u"t"n otot &"?&$ : 6?6+ RO2 &"?&$ : "&t$.?"&t$.
E&tre#$t" *">"h : &e&u"t"n otot &"?&$: 6?6+ RO2 &"?&$ : "&t$.?"&t$.
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D$"no" Keper">"t"n
49 Kont$p"$ *9- penurun"n "up"n/"$r"n -"n er"t+ &e%e#"h"n otot"*-o#en e&un-er "&$*"t C"
Co%ore/t"%99 D$"re *9- proe peny"&$t9
19 Nyer$ "&ut *9- proe peny"&$t9
;9 Ket$-"&e$#*"n"n nutr$$ &ur"n -"r$&e*utuh"n tu*uh *9- #u"%?#unt"h9
79 An$et" *9- proe peny"&$t
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KASUS
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Tn9 C (;7 th! -"t"n &e po%$&%$n$& RSUD Dr9 Soeto#o -n&e%uh"n nyer$ -$ -"er"h perut *"$"n &$r$ *">"h9 Su-"h 1#$nu $n$ BAB ny" e%"%u *er%en-$r -"n *er-"r"h+ 4#$nu ter"&h$r $n$ BAB ny" *er-"r"h e"r er$n u"#en"%"#$ o*t$p"$+ &"-"n u" #en"%"#$ &e#*un+&%$en #er"" *"h>" BBny" turun (BB ">"% 35 &!+ t$-"&n".u #"&"n+ #u"%+ #unt"h -"n u" nyer$ ""t BAB9
K%$en #en"t"&"n t$-"& t"hu peny"&$t "p" y"n-$-er$t"ny" ""t $n$9 Ke%u"r" #en"t"&"n p"$en %e*$hen"n #"&"n -"$n+ "y"# -"n "r"n #"&"n "yur9
S""t pe#er$&""n 8$& -$-"p"t -"t" : KU %e#"h+ TT4;5?F5 ##H+ N: 455?#en$t+ uhu 13+;5C + RR :
5?#en$t+ /onunt$," "ne#$+ -$ten$ "*-o#en+ nyer$te&"n -$ "*-o#en9 H"$% /o%ono/opy: *er*entu& $r&u%er-"n "nu%er -"n penye#p$t"n %u#en uu -"n tr$&tur"#enono% -"n #en$$9 K%$en -$-$"no$ C" Co%on9
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Pen&"$"n
49 An"#ne""9D"t" De#or"8 K%$en
*9Ke%uh"n ut"#"
K%$en #ene%uh nyer$ -$ -"er"h perut *"$"n &$r$
*">"h/9 RPS
K%$en #ene%uh u-"h 1 #$nu BABny" *er%en-$r-"n *er-"r"h -"n 4 #$nu ter"&h$r $n$ BAB ny"-"r"h e"r9 K%$en er$n #en"%"#$ o*t$p"$+&"-"n u" #en"%"#$ -$ten$ "*-o#en+ u-"h4 *u%"n $n$ BB &%$en turun (BB ">"% 35 &!+ t$-"&n".u #"&"n -"n u" nyer$ ""t BAB
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-9 RPD
T$-"& "-" r$>"y"t >"$r
e*e%u#ny" Ser$n &ont$p"$
Per"""n *u"n "$r *e"r t$-"&
tunt"e9 RPK
R$>"y"t &e%u"r" t$-"& pern"h
#en-er$t" &e%uh"n y"n "#"-en"n y"n -$-er$t" &%$en9
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9 Pe#er$&""n '$$&B1 Br!at"ing# B!nt*k dada si+!tris, RR $- kali . +!nit, tidak
ada /!ngg*naan otot 0ant* /!rna/asan, tidakada r!traksi dinding dada, s*ara na/as
!sik*l!r2B$ Blood#
A&r"% ter"*" h"n"t+ TD 4;5?F5 ##H+ n"-$ ter"*"
&u"t+ n"-$ 455 &"%$?#en$t+ CRT -et$&+ T: 13+;oC+
/onunt$," "ne#$
B% Brain#
Ke"-"r"n /o#po#ent$ -en"n GCS 47+ E ; 7 2 6+ re"&$ pup$% $o&or 1? ( &"n"n !+1? ( &$r$ !+
re=e& /"h"y" ? B& Bladd!r#
B$""ny" BAK 706 ?h"r$ pont"n9
B' Bo(!l# BAB ter"&h$r *er%en-$r -"n -"r"h e"r -"n er$n
u" #en"%"#$ o*t$p"$+ nyer$ ""t BAB+ -$ten$
"*-o#en+ BB &%$en turun #en"-$ 76 & (BB ">"% 35
&!+ t$-"& n".u #"&"n
B) Bon!# E&tre#$t" "t" :
T$-"& "-" o-e#"+ tonu otot 7+ CRT -t&+ t$-"&
"-" %e$9
E&te#$t" *">"h:
T$-"& "-" o-e#"+ tonu otot 7+ CRT -t&9
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Pe#er$&""n Penun"n
Co%ono/opy: *er*entu& $r&u%er -"n"nu%er -"n penye#p$t"n %u#en uu-"n tr$&tur" #enono% -"n #en$$
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An"%$" D"t"No
2
SI4N AND S5MPTOM ETIOLO
4I
PROBLEM
12 DS:
- P"$en #en"t"&"n u-"h 1
#$nu $n$ BAB ny" e%"%u
*er%en-$r -"n *er-"r"h+
-P"$en #en"t"&"n 4 #$nuter"&h$r $n$ BAB ny" -"r"h
e"r
- P"$en #en"t"&"n nyer$
""t BAB -"n #en"%"#$
o*t$p"$
DO:
- KU %e#"h
-TT 4;5?F5 ##H+ N:
455?#en$t+ uhu 13+;5C +
RR : 5?#en$t+
-Conunt$," "ne#$
- Co%ono/o : *er*entu&
G"nu"n
"tro$ntet$
n"%
Re$&o
Per-"r"h"n
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$2 DS 6
- Pasi!n +!ng!l*" n7!ri di da!ra"
/!r*t 0agian kiri 0a(a"
DO6
-Skala n7!ri6 8
- P!rilak* +!lind*ngi ar!a 7ang
sakit dan distraksi
- R!s/on a*tono+ s!/!rti
dia/"or!sis, /!ningatan t!kanan
dara", /!ningkatan nadi#
-Tingka" lak* !ks/r!si9 :onto" 6
g!lisa", +!rinti", +!nangis,
(as/ada, irita0!l, na9as
/an;ang.0!rk!l*" k!sa"#
- N7!ri t!kan /al/asi# /ada /!r*t
0agian kiri 0a(a"- Dist!nsi a0do+!n
- TD6 1&-.
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%2 DS6
- Pasi!n +!ngatakan
s*da" 1 0*lan ini BB
kli!n t*r*n BB a(al 8-kg#
- Pasi!n +!ngatakan tidak
na9s* +akan
- K!l*arga /asi!n
+!ngatakan, +akanan/asi!n tidak "a0is,
"an7a "a0is $ s!ndok
- Pasi!n +!ngatakan
s!ring +!ngala+i +*al
dan +*nta"
DO6- KU l!+a"
- Pasi!n t!rli"at
:on;*ngtia an!+is
- BB6 ') kg
- N7!ri t!kan /al/asi#
/ada /!r*t 0agian kiri
Anor!ksia,
+*al,
+*nta"
K!tidaks!i+0a
ngan n*trisi
k*rang dari
k!0*t*"ant*0*"
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&2 DS6
- Pasi!n +!ngatakan s!ring
s*sa" *nt*k BAB o0sti/asi#
- Pasi!n +!ngatakan tidak
na9s* +akan
-Pasi!n +!ngatakan kadang
;*ga +!ngala+i k!+0*ng
dist!nsi a0do+!n#
- Pasi!n +!ngatakan n7!ri
t!kan /ada a0do+!n
- K!l*arga +!ngatakan /asi!n
l!0i" s!nang +akan daging,a7a+ dan ;arang +akan sa7*r
DO6
- Pasi!n t!rli"at :on;*ngtia
an!+is,
- P!r*t /asi!n t!rli"at agak
+!+0!sar dist!nsia0do+!n#
P!n7!+/itan
l*+!n dan
strikt*r
Konsti/asi
'2 DS: p"$en #en"t"&"n t$-"& t"hu
tent"n peny"&$tny"
DO:
- K%$en er$n *ert"ny" tent"n
peny"&$tny" p"-" per">"t
-K%$en t"#p"& *$nun
Kur"n
$n.or#"$
De8$en$
penet"hu"n
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D$"no" Keper">"t"n
49 Re$&o per-"r"h"n *9- ."&tor re$&o"nu"n "tro$ntet$n"%
9 Nyer$ "&ut *9- "en $nury *$o%o$
19 Ket$-"&e$#*"n"n nutr$$ &ur"n -"r$&e*utuh"n tu*uh *9- "nore&$"+ #u"%+#unt"h
;9 Kont$p"$ *9- penye#p$t"n %u#en -"n
tr$&tur79 De8$en$ penet"hu"n *9- &ur"n
$n.or#"$
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Inter,en$ Keper">"t"n
Seu"$&"n -en"n NOC NIC 5470
543
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TERI2AKASIH