KMB 1=Askep Sirosis Hepatis
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Askep Sirosis Hepatis
By Gad Datak
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Review Anatomi & Fisiologi Hati
a. Weighing between 1,200 and 1,600 g, the liver is the largest glandular organ in the body. It is located in the right upper abdominal quadrant, under the right diaphragm.
b.The liver is divided into four lobes: left, right, caudate and quadrate. The lobes are further subdivided into smaller units known as lobules.
c. The liver contains several cell types including hepatocytes (ie. Liver cells) and Kupffer cells (i.e. phagocytic cells that engulf bacteria).
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d. Bile is continuously formed by hepatocytes (about 1L/day). Bile comprises water, electrolytes , lecithin,fatty acids, cholesterol, bilirubin and bile salts.
e. The Liver is surrounded by a tough fibroelastic capsule called Glisson’s capsule.
Lanjutan review anatomi & fisiologi hati.....
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Function Of The Liver• Regulating blood glucose level by making glycogen,
which is stored in hepatocytes.• Synthesizing blood glucose from amino acids of
lactate through gluconeogenesis.• Converting ammonia produced from
gluconeogenetic by-products and bacteria to urea• Synthesizing plasma proteins such as albumin,
globulins, clotting factors, and lipoproteins.• Breaking down fatty acids into ketone bodies• Storing vitamins and trace metals• Affecting drug metabolism and detoxification• Secreting bile
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Sirosis Hepatis• Suatu keadaan patologis yg menggambarkan
stadium akhir fibrosis hepatik yg berlsg progresif yg ditandai dgn distorsi dari arsitektur hati & pembentukan nodulus regeneratif akibat nekrosis hepatoseluler
• Secara klinis dibagi : Sirosis hati kompensata belum adanya gejala
klinis yg nyata Sirosis hati dekompensata ditandai gejala-
gejala & tanda klinis yg jelas
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Epidemilogi
Lebih dari 40% pasien asimptomatis Insidens di USA 360 per 100.000
penduduk Di Indonesia belum ada data
prevalensi hanya laporan dari pusat pendidikan, ex : di RSUP Sardjito 4,1% pasien di rawat di bagian penyakit Dalam dlm kurun 1 tahun (2004)
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• Di negara barat disebabkan oleh alkohol • Di Indonesia oleh virus hepatitis B
(40-50%), C (30-40%) & 10-20% tidak diketahui (virus non A non B)
Etiologi Sirosis Hepatitis
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Lanjutan Etiologi Sirosis Hepatitis
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Manifestasi Klinis
Stadium awal sering tanpa gejala Gejala awal sirosis ( kompensata)
mudah lelah, lemas, selera makan kurang, perasaan perut kembung, mual, BB menurun, impotensi, testis mengecil, buah dada membesar, hilangnya dorongan seksual
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Lanjutan Manifestasi Klinis......
Sirosis dekompensata timbulnya komplikasi kegagalan hati & hipertensi porta : ikterus, urine berwarna teh pekat, hilangnya rambut badan, insomnia, demam tdk begitu tinggi, perdarahan gusi, epistaksis, ggn pembekuan darah, ggn siklus haid, muntah & atau melena, perubahan mental (mudah lupa, sukar konsentrasi, bingung, agitasi, bahkan sampai koma).
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Temuan Klinis
Spider angioma-spiderangiomata (spidertelangiektasi) lesi vaskular yg dikelilingi beberapa vena vena kecil di bahu, muka & lengan atas diduga peningkatan rasio estradiol/testoteron bebas
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Lanjutan temuan klinis.....
Eritema palmaris warna merah saga pd thenar & hipothenar telapak tangan perubahan metabolisme estrogen
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Lanjutan temuan klinis.....
Perubahan kuku-kuku murchrche berupa pita putih horisontal dipisahkan dgn warna normal kuku diperkirakan oleh hipoalbuminemia & ditemukan jg pd nefrotik syndrom
Jari gada sirosis bilier
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Lanjutan temuan klinis.....
Hati sirotik teraba keras & nodular
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Lanjutan temuan klinis.....
Caput medusa akibat hipertensi porta
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Lanjutan temuan klinis.....
Asites penimbunan cairan dlm rongga peritonium akibat hipertensi porta & hipoalbuminemia
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Lanjutan temuan klinis.....
Splenomegali sirosis hepatis penyebabnya non alkholik akibat pembesaran pulpa merah lien karena hipertensi porta
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Lanjutan temuan klinis.....
Ikterus kulit & membran mukosa akibat bilirubinemia
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Lanjutan temuan klinis.....
Urine seperti warna teh
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Lanjutan temuan klinis.....
Fetor hepatikum bau napas yg khas pd pasien sirosis peningkatan konsentrasi dimetil sulfid akibat pintasan porto sistemik yg berat
Ginekomastia peningkatan androstonedion pd laki laki &
fase menopause pd wanita
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Lanjutan temuan klinis.....
Atropi testis hipogonadisme impotensi & infertil menonjol pd sirosis alkoholik
Hilangnya rambut dada & aksila pd laki laki cenderung feminisme
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Diagnostik Tes Fungsi Hati :
Bilirubin meningkat pd sirosis dekompensata Albumin menurun sesuai perburukan sirosis SGPT & SGOT meningkatProtrombin time memanjang mencerminkan
derajat disfungsi sintesis hati Globulin meningkat akibat pintasan antigen
bakteri dari sistem porta ke jaringan limfoid Natrium menurun (sirosis dgn asites)
ketidakmampuan eskresi air bebas
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Lanjutan diagnostik......
Tes Fungsi Hati : alkali fosfatase meningkat 2-3 kali nilai batas
normal Gamma Glutamil Transpeptidase (GGT)
meningkat oleh alkohol yg menginduksi GGT mikrosomal hepatik bocornya GGT dari hepatosit
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Lanjutan diagnostik......
Pemeriksaan radiologis barium meal melihat varises utk konfirmasi adanya hipertensi porta
USG hati mengecil & nodular, permukaan irreguler , adanya peningkatan ekogenitas parenkim hati. Asites, splenomegali, trombosis vena porta & pelebaran vena porta
Biopsi hati
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Komplikasi Peritonitis bakterial spontan infeksi cairan
asites oleh satu jenis bakteri tanpa ada bukti infeksi sekunder intraabdominal demam & nyeri abdomen
Varises esofagus (20%-40%) perdarahan 2/3 akan meninggal dlm 1 thn mortalitas tinggi
Sindrom hepatorenal GGA oliguri, kreatinin & ureum tanpa kelainan organik ginjal. Lebih lanjut penurunan perfusi ginjal LFG
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Lanjutan komplikasi......
Ensefalopati hepatik kelainan neuropsikiatrik akibat disfungsi hati insomnia & hipersomnia berlanjut sampai koma
Sindrom hepatopulmonal hidrotoraks & hipertensi
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Pengobatan
Sirosis Hepatis Kompensata mengurangi progesif kerusakan hati & menghilangkan etiologi
Hindari alkohol & bahan bahan toksikSteroid & imunosupresif hepatitis autoimunPenurunan BB mencegah sirosis hepatis
penyakit hati non alkoholik
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Lanjutan pengobatan .....
Lamivudin & interferon alfa terapi utama hepatitis B
Kombinasi interferon dgn ribavirin hepatitis C
Metotreksat & vitamin A anti fibrosis Herbal dlm penelitian
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Lanjutan Pengobatan ........
Sirosis Hepatis Dekompensata Asites
– Tirah baring & diet rendah garam (5,2 gr/hari)– DiuretikSpironalakton monitor BB dgn
penurunan 0,5 kg/hari tanpa edema atau 1kg/hari dgn edema jika tidak adekuat ditambahkan Furosemid 20-40 mg/hari tidak berespon 160 mg/hari – Parasintesis asites sgt besar cairan asites
4-6 liter + pemberian albumin
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Parasentesis
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Lanjutan Pengobatan ........ Varises Esofagus– Sengstaken-
Blakemore Tube (SB Tube) tamponade balon utk mengendalikan perdarahan– Beta blocker
(propanolol) sebelum & sesudah perdarahan
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Lanjutan Pengobatan ........
Varises Esofagus– Preparat somatostatin/oktreotid
perdarahan akut ligasi endoskopi
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Lanjutan Pengobatan ........
Ensefalopati Hepatik– Laktulosa mengeluarkan amonia– Neomisin mengurangi bakteri
penghasil amonia– Diet protein sampai 0,5 gr/hari
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Lanjutan Pengobatan ........
Peritonitis bakterial spontan antibiotika sefotaksim IV, amoksilin, aminoglikosida
Sindroma hepatorenal mengatur keseimbangan cairan garam & air
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Nursing Management Assesment (Data Subjektif)Kaji riwayat kesehatan sebelumnya : hepatitis,
penyakit virus, toksik, gagal jantung, infeksi, riwayat pengobatan
Kaji pola kesehatan : status nutrisi (anoreksia, dispepsia, muntah, kehilangan bb, perdarahan gusi), persepsi & pengelolan kesehatan ( alkohol kronik, fatigue & kelemahan)
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Lanjutan assesment......
eliminasi (urine seperti teh pekat, feses berwarna hitam, flatulens, perubahan pola BAB, penurunan urine output, kulit kuning dll), persepsi-kognitif (nyeri abdomen kuadran kanan atas, mati rasa, kesemutan, pruritus), seksual reproduksi (impotensi,amenorrhea)
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Assesment (Data Objektif) Umum (demam, kakeksia), integumen (sklera
ikterus, jaundice, petechiae, spider angioma, alopesia, edema perifer, erithema palmar), respirasi(epistaksis, pernapasan cepat & dangkal), GIT (distensi abdomen, asites, caput medusa, hematemesis, feses berwarna hitam, hepatomegali & splenomegali , hemoroid), neurologi (ggn mental), reproduksi (ginekomastia, atropi testis, impotensi, amenorrhea, loss of libido)
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Assesment (Data Objektif) data yg lain : anemia, leukopenia,
trombositopenia, penurunan serum (albumin, kalium), fungsi hati abnormal, ggn pembekuan darah, dll)
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Diagnosa Keperawatan Ketidakseimbangan nutrisi ;kurang dari kebutuhan
tubuh b.d ggn penggunaan & penyimpanan nutrisi, anoreksia, nausea, kehilangan nutrisi akibat muntah
Tujuan : intake nutrisi adekuat, BB dlm batas normal Intervensi :1. Monitor berat badan2. Lakukan oral care sebelum makan3. Berikan makanan porsi kecil tp sering4. Berikan obat sesuai order, misalnya antiemetik5. dll
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Lanjutan diagnosa keperawatan..................... Ggn integritas kulit b.d pruritus, edema, ascites Tujuan : integritas kulit terpelihara, pruritus
berkurang Intervensi :1. Batasi intake natrium2. Batasi cairan sesuai order3. Monitor intake & output cairan4. Kaji lokasi & luasnya edema5. Tinggikan daerah yg edema6. Berikan obat sesuai order: antipruritus, antidiuretik,
dll
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Lanjutan diagnosa keperawatan..................... Tidak efektifnya pola napas b.d penekanan
diafragma & pengurangan volume paru sekunder terhdp asites
Tujuan : pola napas efektif, tdk ada sianosis & keluhan hipoksia, mampu bernapas dgn kesulitan minimal
Intervensi :1. Tempatkan pasien posisi semifowler atau fowler2. Auskultasi bunyi paru3. Kaji irama dan kecepatan pernapasan
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Lanjutan diagnosa keperawatan..................... Potensial komplikasi : hemoragik b.d kecenderungan
perdarahan sekunder terhdp ggn faktor pembekuan & ruptur esofageal atau varises gastric
Intervensi :1. Batasi aktifitas fisik2. Monitor tanda-tanda perdarahan : epistaksis,
petechie, perdarahan gusi, hemturi, melena3. Anjurkan menggunakan sikat gigi yg lunak4. Anjurkan pasien menghindari mengedan yg kuat,
meniup napas yg kuat melalui hidung & batuk5. Monitor hasil laboratorium : Hb, Ht, PT, APTT6. Lakuan tindakan keperawatan dgn hati-hati
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