LAPORAN PENDAHULUAN ASKEP GAGAL GINJAL KRONIK

Definisi

Penyakit gagal ginjal kronis bersifat progresif dan irreversible dimana terjadi uremia karena kegagalan tubuh untuk mempertahankan metabolisme dan keseimbangan cairan serta elektrolit ( SmeltzerC, Suzanne, 2002 hal 1448)

Gagal ginjal kronis ini merupakan penyakit ginjal tahap akhir

Etiologi

• Glomerulonefritis kronis
• Pielonefritis
• Diabetes mellitus
• Hipertensi yang tidak terkontrol
• Obstruksi saluran kemih
• Penyakit ginjal polikistik
• Gangguan vaskuler
• Lesi herediter
• Agen toksik (timah, kadmium, dan merkuri)

( SmeltzerC, Suzanne, 2002 hal 1448)

asuhan keperawatan pada klien dengan GGK

Patofisiologi

Penurunan GFR

Pemeriksaan klirens kreatinin dengan mendapatkan urin 24 jam untuk mendeteksi  penurunan GFR. Akibat dari penurunan GFR, maka klirens kretinin akan menurun, kreatinin akan meningkat, dan nitrogen urea darah (BUN) juga akan meningkat.

Gangguan klirens renal

Banyak masalah muncul pada gagal ginjal sebagai akibat dari penurunan jumlah glomeruli yang berfungsi, yang menyebabkan penurunan klirens (substansi darah yang seharusnya dibersihkan oleh ginjal).

Retensi cairan dan natrium

Ginjal kehilangan kemampuan untuk mengkonsentrasikan atau mengencerkan urin secara normal. Terjadi penahanan cairan dan natrium sehingga  meningkatkan resiko terjadinya edema, gagal jantung kongestif dan hipertensi.

Anemia

Anemia terjadi sebagai akibat dari produksi eritropoetin yang tidak adekuat, memendeknya usia sel darah merah, defisiensi nutrisi, dan kecenderungan untuk terjadi perdarahan akibat status uremik pasien, terutama dari saluran GI.

Ketidakseimbangan kalsium dan fosfat

Kadar serum kalsium dan fosfat tubuh memiliki hubungan yang saling timbal balik, jika salah satunya meningkat, yang lain akan turun. Dengan menurunnya GFR, maka terjadi peningkatan kadar fosfat serum dan sebaliknya akan terjadi penurunan kadar kalsium. Penurunan kadar kalsium ini akan memicu sekresi paratormon, namun dalam kondisi gagal ginjal, tubuh tidak berespon terhadap peningkatan sekresi parathormon, akibatnya kalsium di tulang menurun menyebabkab perubahan pada tulang dan penyakit tulang.

Penyakit tulang uremik (osteodistrofi)

Terjadi dari perubahan kompleks kalsium, fosfat, dan keseimbangan parathormon.

( SmeltzerC, Suzanne, 2002 hal 1448)

Manifestasi Klinik

Kardiovaskuler

-              Hipertensi

-              Pembesaran vena leher

-              Pitting edema

-              Edema periorbital

-              Friction rub pericardial

Pulmoner

-            Nafas dangkal

-            Krekels

-            Kusmaul

-            Sputum kental dan liat

Gastrointestinal

-                 Konstipasi / diare

-                 Anoreksia, mual dan muntah

-                 Nafas berbau amonia

-                 Perdarahan saluran GI

-                 Ulserasi dan perdarahan pada mulut

Muskuloskeletal

-                 Kehilangan kekuatan otot

-                 Kram otot

-                 Fraktur tulang

Integumen

-                 Kulit kering, bersisik

-                 Warna kulit abu-abu mengkilat

-                 Kuku tipis dan rapuh

-                 Rambut tipis dan kasar

-                 Pruritus

-                 Ekimosis

Reproduksi

-               Atrofi testis

-               Amenore

( SmeltzerC, Suzanne, 2002 hal 1450)

Pemeriksaan Diagnostik

a.       Urin

-          Warna: secara abnormal warna urin keruh kemungkinan disebabkan oleh pus, bakteri, lemak, fosfat atau uratsedimen. Warna urine kotor, kecoklatan menunjukkan adanya darah, Hb, mioglobin, porfirin

-          Volume urine: biasanya kurang dari 400 ml/24 jam bahkan tidak ada urine (anuria)

-          Berat jenis: kurang dari 1,010 menunjukkn kerusakan ginjal berat

-          Osmolalitas: kurang dari 350 mOsm/kg menunjukkan kerusakan ginjal tubular dan rasio urin/serum sering 1:1

-          Protein: Derajat tinggi proteinuria (3-4+) secara kuat menunjukkkan kerusakan glomerulus bila SDM dan fragmen juga ada

-          Klirens kreatinin: mungkin agak menurun

-          Natrium: lebih besar dari 40 mEq/L karena ginjal tidak mampu mereabsorbsi natrium

b.      Darah

-          Ht : menurun karena adanya anemia. Hb biasanya kurang dari 7-8 gr/dl

-          BUN/ kreatinin: meningkat, kadar kreatinin 10 mg/dl diduga tahap akhir

-          SDM:  menurun, defisiensi eritropoitin

-          GDA: asidosis metabolik, pH  kurang dari 7,2

-         Protein (albumin) : menurun

-         Natrium serum : rendah

-         Kalium: meningkat

-         Magnesium: meningkat

-         Kalsium ; menurun

c. Osmolalitas serum:

Lebih dari 285 mOsm/kg

d. Pelogram Retrograd:

Abnormalitas pelvis ginjal dan ureter

e. Ultrasonografi Ginjal :

Untuk menentukan ukuran ginjal dan adanya masa , kista, obstruksi pada saluran perkemihan bagian atas

f. Endoskopi Ginjal, Nefroskopi:

Untuk menentukan pelvis ginjal, keluar batu, hematuria dan pengangkatan tumor selektif

g. Arteriogram Ginjal:

Mengkaji sirkulasi ginjal dan mengidentifikasi ekstravaskular, masa

h. EKG:

Ketidakseimbangan elektrolit dan asam basa

(Doenges, E Marilynn, 2000, hal 628- 629)

Penatalaksanaan

1.       Dialisis

2.       Obat-obatan: anti hipertensi, suplemen besi, agen pengikat fosfat, suplemen kalsium, furosemid

3.       Diit rendah uremi

( SmeltzerC, Suzanne, 2002 hal 1449)

Komplikasi

1.      Hipertensi

2.      Hiperkalemia

3.      Perikarditis, efusi pericardial dan tamponade jantung

4.      Anemia

5.      Penyakit tulang

( SmeltzerC, Suzanne, 2002 hal 1449)

Fokus Pengkajian

1.      Aktifitas /istirahat

Gejala:

-          Kelemahan malaise

-          Kelelahan ekstrem,

-          Gangguan tidur (insomnis/gelisah atau somnolen)

Tanda:

-       Kelemahan otot, kehilangan tonus, penurunan rentang gerak

2.      Sirkulasi

Gejala:

-       Riwayat hipertensi lama atau berat

-       Palpitasi, nyeri dada (angina)

Tanda:

-          Hipertensi, nadi kuat, edema jaringan umum dan piting pada kaki, telapak tangan

-          Nadi lemah, halus, hipotensi ortostatik

-          Disritmia jantung

-            Pucat pada kulit

-            Friction rub perikardial

-            Kecenderungan perdarahan

3.             Integritas ego

Gejala:

-          Faktor stress, misalnya masalah finansial, hubungan dengan orang lain

-          Perasaan tak berdaya, tak ada harapan

Tanda:

- Menolak, ansietas, takut, marah, perubahan kepribadian,  mudah terangsang

4.             Eliminasi

Gejala:

-          Penurunan frekuensi urin, oliguria, anuria ( gagal tahap lanjut)

-          Diare, Konstipasi, abdomen kembung,

Tanda:

-          Perubahan warna urin, contoh kuning pekat, coklat, kemerahan,   berawan

-        Oliguria, dapat menjadi anuria

5.  Makanan/cairan

Gejala:

-    Peningkatan BB cepat (edema), penurunan BB (malnutrisi)

-    Anoreksia, mual/muntah, nyeri ulu hati, rasa metalik tak sedap pada mulut ( pernafasan amonia)

Tanda:

-    Distensi abdomen/ansietas, pembesaran hati (tahap akhir)

-    Edema (umum, tergantung)

-    Perubahan turgor kulit/kelembaban

-    Ulserasi gusi, perdarahan gusi/lidah

-    Penurunan otot, penurunan lemak subkutan, penampilan tak bertenaga

6.       Neurosensori

Gejala:

-    Kram otot/kejang, sindrom kaki gelisah, kebas rasa terbakar pada Sakit kepala, penglihatan kabur

-    telapak kaki

-    Kebas/kesemutan dan kelemahan khususnya ekstrimitas bawah (neuropati perifer)

Tanda:

-    Gangguan status mental, contohnya ketidakmampuan berkonsentrasi, kehilangan memori, kacau, penurunan tingkat kesadaran, penurunan lapang perhatian, stupor, koma

-    Kejang, fasikulasi otot, aktivitas kejang

-    Rambut tipis, kuku tipis dan rapuh

7.       Nyeri/kenyamanan

Gejala:, sakit kepala, kram otot/nyeri kaki, nyei panggul

Tanda: perilaku berhati-hati/distraksi, gelisah

8.       Pernapasan

Gejala:

-    Dispnea, nafas pendek,  nokturnal paroksismal, batuk dengan/tanpa sputum

Tanda:

-    Dispnea, takipnea pernapasan kusmaul

-    Batuk produktif dengan sputum merah muda encer (edema paru)

9.       Keamanan

Gejala: kulit gatal, ada/berulangnya infeksi

Tanda:

-    Pruritus

-    Demam (sepsis, dehidrasi)

10.         Seksualitas

Gejala: amenorea, infertilitas, penurunan libido

11.         Interaksi sosial

Gejala:

-          Kesulitan menurunkan kondisi, contoh tak mampu bekerja, mempertahankan fungsi peran dalam keluarga

12.         Penyuluhan

-                 Riwayat diabetes mellitus pada keluarga (resti GGK), penyakit polikistik, nefritis herediter, kalkulus urinaria

-                 Riwayat terpajan pada toksin, contoh obat, racun lingkungan

-                 Penggunaan antibiotik nefrotoksik saat ini/berulang

(Doenges, E Marilynn, 2000, hal 626- 628)

Penyakit pada kaki

Sakit kaki: Sebab dan Rawatan

Posted on December 1, 2010 by sitik

Kita biasa melihat orang yang sakit kaki, walaupun sakit kaki bukanlah dianggap kritikal (jika tidak berkait dengan penyakit-penyakit kritikal seperti diabetes, gout, arthritis), namun sakit kaki akan menyusahkan seseorang untuk bergerak ke sana ke mari.
Terdapat berbagai jenis penyebab sakit kaki dan cara rawatan juga adalah berbeza-beza, mengikut sebab dan tempat sakit tersebut, sama ada di kaki, di tapak kaki, di ibu jari, jari, bahagian tepi kaki dan sebagainya. Selain daripada penyakit gout, arthritis, dan sakit saraf, sakit kaki juga biasanya disebabkan memakai kasut yang tidak sesuai dengan kaki, saluran darah yang kurang lancar di kaki, penyakit kulit, tulang, ligamen, tendon, otot, dan sebagainya.
Berikut disenaraikan beberapa jenis penyebab sakit kaki yang biasa dan cara-cara rawatan asas yang sesuai untuk sakit kaki yang berlainan…

Foot Pain
Reviewed by Louise Chang, MD
Foot pain is one of the most common problems people experience. There are many different causes of foot pain. Foot pain treatments include rest, pain relievers, stretching exercises, and change in habits or footwear. Surgery may be helpful for some people with foot pain.
Causes of Foot Pain
Pain in the foot can be due to a problem in any part of the foot. Bones, ligaments, tendons, muscles, fascia, toenail beds, nerves, blood vessels, or skin can be the source of foot pain.
The cause of foot pain can be narrowed down by location and by considering some of the most common causes of foot pain.
Heel Pain
Plantar fasciitis is the most common cause of heel pain. The plantar fascia, a band of tough tissue connecting the heel bone to the toes, becomes irritated or inflamed. Heel pain, worst in the morning when getting out of bed, is the most common symptom. Arch pain may also be present.
Treatment for plantar fasciitis includes:
* rest
* calf muscle stretches
* over-the-counter pain relievers
* shoes with good arch support and a cushioned sole
Various other treatments for plantar fasciitis are available.
Heel spurs are abnormal growths of bone on the bottom of the heel bone, which may cause foot pain during walking or standing. Although one in 10 people has heel spurs, only one in 20 of these people will have foot pain. Heel spurs can occur in people with plantar fasciitis, but they do not cause plantar fasciitis. People with flat feet or high arches are more likely to have foot pain from heel spurs.
Treatment for heel spurs include:
* cutout heel pad
* custom-made insert (orthotic) worn in the shoe
* over-the-counter pain relievers
* rest
* surgery (rarely)
A stone bruise is a bruise of the fat pad of the heel. It can occur after stepping on a rock or other hard object, The heel color may not appear bruised, but the heel pain gets better with rest.
A fracture of the heel bone (calcaneus) is the most commonly fractured foot bone. It is most often caused by high impact to the heel — for example, when person has fallen from a height or been in a car accident. Injuries can range from a bone crack from a new vigorous exercise plan to a shattered bone from a high fall. Heel pain, bruising, swelling, limping, or difficulty walking are the main symptoms.
Calcaneus fracture treatment includes:
* rest from weight bearing, often with crutches
* thorough padding of the heel
* splinting or casting to protect the heel bone
* pain relievers
* surgery
Ball of Foot Pain
Metatarsalgia produces pain and inflammation in the ball of the foot. Strenuous activity or ill-fitting shoes are the usual causes.
Treatment for metatarsalgia includes:
* pain relievers
* change to more comfortable footwear
* inserts for the shoes to relieve pressure on the ball of the foot
Morton’s neuroma is thickening of the tissue around the nerve between the bases of the toes (usually between the third and fourth toes). Foot pain, odd sensations, or numbness over the ball of the foot are the usual symptoms. It is more common in women and can be a result of wearing high heels or tight shoes.
Morton’s neuroma treatment includes:
* shoe inserts to reduce pressure on the nerve.
* steroid injection into the area of foot pain
* pain relievers
* surgery (occasionally)
Sesamoiditis occurs when tendons around the big toe are injured and inflamed.
Treatment for sesamoiditis includes:
* rest
* ice
* wearing a foot pad under the toe in a comfortable shoe
* wearing low-heeled shoes
* steroid injections may be helpful in some cases
Arch Pain
Arch pain is most often caused by plantar fasciitis, which can affect the heel, arch, or both. Plantar fasciitis treatment is the same, regardless of the location of foot pain (see above). For persistent plantar fasciitis, an injection with a mixture of a steroid and local anesthetic can be helpful.
Fallen arches — or flat feet — occurs when the arches of the feet flatten out (often when standing or walking), causing foot pain and other problems. Flat feet can be treated with shoe inserts (orthotics), shoe adjustments, rest/ice, using a walking case or brace, or physical therapy. Occasionally, surgery is necessary.
Toe Pain
Arthritis , including gout, can cause pain in the toes. Gout is an inflammatory condition in which crystals periodically deposit in joints, causing severe pain and swelling. The big toe is often affected by gout.
Treatment for gout includes:
* rest
* medication such as colchicine or prednisone
* pain relievers
* daily medication and diet restriction to prevent gout attacks
A bunion (hallux valgus) is a bony prominence along the edge of the foot, next to the base of the big toe. Bunions may occur in anyone, but are often caused by ill-fitting footwear in women. Hammer toes often occur with bunions.
Bunion treatment includes:
* Changing to more comfortable shoes; if this is unsuccessful in relieving foot pain, surgery may be considered.
Hammer toe occurs when the near joint in the toe is bent, creating a hammer-like appearance. Wearing tight shoes is the main cause of hammer toe.
Claw toe occurs when the joint at the end of a toe may become unable to straighten, causing the toe to point down or up. Irritation of the feet and other feet problems may develop, without special footwear to accommodate the claw toe.
Treatment of hammer toe and claw toe includes:

* changing to better-fitting footwear; avoiding high heels and tight shoes
* stretching exercises for toes and toe joints
* shoe inserts
* orthotics
* surgery may sometimes be necessary
Ingrown toenails occur when skin on one or both sides of a toenail grow over the nail. Ingrown toenails may be painful or lead to infections.
Treatment for ingrown toenail includes:
* Soak the foot in warm water four times a day.
* Once daily, wedge a piece of gauze between the nail and wet skin.
Turf toe refers to pain at the base of the big toe resulting from athletic activities. Turf toe is an overuse injury usually caused by strain from running or jumping. Turf toe may also be a form of sesamoiditis or sesamoid fracture.
Toe fracture may occur in any of the bones of the toes. Minor fractures may only require rest, ice, and pain relievers; serious fractures can require foot immobilization and surgery. Any suspected fracture should be evaluated by a doctor.
Toe sprain may occur when jamming or stubbing of the toe damages the tendon or soft tissues of the toe. If no fracture is present, the pain and swelling of a toe sprain should subside within days.
Hallux rigidus (toe arthritis) is a degenerative arthritis (osteoarthritis) at the base of the big toe. Pain and stiffness of the joint, worsening over time, are symptoms. Treatment can include pain relievers and stretching exercises. Surgery may be needed in some cases.
Corns are thick buildups of tough skin on a point of irritation or pressure on the foot or toe. Corns often have a horn-like appearance.
Callus is a wider area of tough skin buildup on the toes or feet, in response to irritation or pressure. Calluses and corns are generally caused by poor-fitting footwear.
Treatment for corns and calluses include:
* wear better-fitting shoes
* use a pumice stone or other abrasive to wear down the extra skin
Sesamoid fracture is a fracture of small bones (sesamoids) that are embedded in tendons attaching to the big toe. Pain in and around the big toe is the main symptom.
Treatment for sesamoid fracture includes:
* rest
* ice
* elevation
* pain relievers
* immobilization of the toe and foot
Surgery may be needed for serious sesamoid fractures.
Pain on the Foot’s Outer Edge
The fifth metatarsal bone (along the outer foot edge) is a commonly fractured bone in the foot. Pain, swelling, and bruising along the outer foot edge after an injury are symptoms.
Treatment for any foot fracture should include medical attention, X-rays, pain relievers, rest, ice, and elevation. Immobilization and surgery may be necessary for some foot fractures.
Foot Pain That’s Anywhere or Everywhere
Neuropathy, or nerve damage in the feet, is most often caused by diabetes. Foot pain can be burning, stinging, or feel like electricity. Neuropathy foot pain can occur anywhere in the feet.
Treatment for neuropathy focuses on the underlying cause, such as diabetes. Medications that act on nerves can also be helpful in reducing foot pain.
Trauma can mean anything from a major crush injury, to the repetitive damage caused by wearing poor-fitting shoes. The foot pain from trauma can occur anywhere on the feet.
Tendinitis is inflammation and irritation of tendons, the bands attaching muscles to bones. Tendons run along all the surfaces of the foot, and can cause foot pain in many different locations. Treatment for tendinitis includes rest and pain relievers; sometimes steroid injections can help. Rarely, surgery is necessary for foot pain from tendinitis.