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Asuhan Keperawatan Kegawatdaruratan Maternal Pada Kasus Ket: Maria Lupita Nena Meo

This document summarizes the nursing care for a case of ectopic pregnancy. It defines ectopic pregnancy as occurring outside the uterus, most commonly in the fallopian tubes. Risk factors, signs and symptoms, and management are described. The nursing care focuses on primary and secondary assessments, monitoring for bleeding and shock, and diagnoses of risk for bleeding related to complications of pregnancy. Goals include reducing blood loss and preventing shock.

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Cathleen Gunawan
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54 views20 pages

Asuhan Keperawatan Kegawatdaruratan Maternal Pada Kasus Ket: Maria Lupita Nena Meo

This document summarizes the nursing care for a case of ectopic pregnancy. It defines ectopic pregnancy as occurring outside the uterus, most commonly in the fallopian tubes. Risk factors, signs and symptoms, and management are described. The nursing care focuses on primary and secondary assessments, monitoring for bleeding and shock, and diagnoses of risk for bleeding related to complications of pregnancy. Goals include reducing blood loss and preventing shock.

Uploaded by

Cathleen Gunawan
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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ASUHAN KEPERAWATAN

KEGAWATDARURATAN
MATERNAL PADA KASUS KET

Maria Lupita Nena Meo


Defenition
• a pregnancy in any location that is outside the
uterus
• The majority occur within the fallopian tube,
with 93–97% implanting in the distal portion
of the tube
• Rarely, pregnancy can occur within the ovary,
the abdominal cavity, the cervix, or adjacent
to Cesarean scar tissue
Perjalanan kehamilan tuba:
• Mati kemudian diabsorbsi
• Abortus tuba  haematocele
• Ruptura tuba
• Keluar dari tuba  tumbuh terus
diabdomen  menjadi kehamilan
abdominal
Dr. Alphonsus Warsanto SpOG
Risk Factor
• lf of all ectopic pregnancies occur in patients
without any known risk factors.
• Traditionally, prior ectopic pregnancy, prior tubal
surgery or other tubal pathology, history of pelvic
inflammatory disease, maternal smoking, and age
over 35 were all associated with increased risk .
• The use of intrauterine devices (IUD) has not
been shown to contribute to overall risk, but
when pregnancy does occur in a patient with an
IUD, it is more likely to be ectopic than
intrauterine
Sign & symptoms
• patients complain of abdominal pain and
vaginal bleeding.
• Many are unaware they are pregnant prior to
ED presentation
• and these patients may report a missed,
delayed, or abnormal menstrual cycle.
• The diagnosis is confirmed by ultrasound
examination.
Tatalaksana
a. Tatalaksana Umum
• Restorasi cairan tubuh dengan cairan kristaloid
NaCl 0,9% atau Ringer
• Laktat (500 mL dalam 15 menit pertama) atau
2 L dalam 2 jam pertama.
• Segera rujuk ibu ke rumah sakit.
Tatalaksana Khusus
• laparotomi
• salpingektomi (eksisi bagian tuba yang
mengandung hasil konsepsi) kika terjadi
kerusakan berat tuba
• Jika terjadi kerusakan ringan pada tuba,
usahakan melakukan salpingostomi untuk
mempertahankan tuba (hasil konsepsi
dikeluarkan, tuba dipertahankan)
• Atasi anemia dengan pemberian tablet besi
sulfas ferosus 60 mg/hari selama 6 bulan.
ASUHAN KEPERAWATAN
PRIMARY SURVEY( simulasi)
• Pemberian posisi untuk
Airway memaksimalkan ventilasi

• Tanda-tanda syok: dispnea,


Breathing hiperventilasi

• Hipotensi, akral dingin, sianosis, pucat ,


Circulation penurunan TD, peningkatan nadi
• Gelisah, bingung, penurunan
Disability
kesadaran pucat (respon syok)

• Seberapa besar sumber perdarahan


Exposure
pervaginam dan komplikasi

• Oliguri sehingga Perlu dilakukan


pemasangan kateter untuk
Folley
Cateter mengukur Urin output
Gastric tube
•-

Heart •EKG
monitor
SECONDARY SURVEY
Pengkajian fokus
• Keluhan utama : Nyeri Abdomen
• Usia: > 35 tahun beresiko tinggi
• Riwayat obstetrik :HPHT, Haid terakhir, riwayat operasi
Tuba, Riwayat infeksi panggul, riwayat penggunaan IUD
• Keadaan umum: gelisah, penurunan kesadaran, cemas,
pucat, akral dingin ( tanda shock)
• TTV: takipnea, takikardi, hipotensi, hipertermi
(endometritis)
• Abdomen:lokasi nyeri
• Genitalia :Perdarahan Abdomen
• Pengkajian tingkat nyeri
• Pemeriksaan penunjang : Tes urin (tes kehamilan
Diagnosa keperawatan

• Resiko perdarahan berhubungan dengan


komplikasi terkait kehamilan(KET)
Masalah keperawatan Tujuan Intervensi

Resiko perdarahan NOC Label: Keparahan NIC label: Pengurangan


berhubungan dengan kehilangan darah perdarahan uterus
komplikasi terkait NOC label: Status sirkulasi antepartum
kehamilan(plasenta NIC label: pencegahan
previa, solutio plasenta) syok
DAFTAR PUSTAKA
• Bulechek, Gloria.M. et al.2013. Nursing Interventions Classification
(NIC) 6th ed. Alih Bahasa: Nurjana, I. USA: Elsevier Mosby Inc
• Depkes. 2013. Buku Saku Pelayanan kesehatan ibu di Fasilitas
kesehatan dasar dan rujukan. Jakarta: DepKes
• Hedman, T Heather. 2016. Nursing Diagnoses: Defenitions and
Classification 2015-2017. Alih Bahasa: Keliat, A.B dkk. Jakarta: EGC
• Moorhead, Sue et al. 2015. Nursing Outcames Classification (NOC)
5th ed. Alih bahasa: Nurjana, I. USA: Elsevier Mosby Inc
• Perry et. Al. 2014. Maternal Child Nursing Care 5 th. Canada:
Elsevier Mosby
• Ward & Shelton. 2009. Maternal & Child Nursing Care.
Philadelphia: F.A Davis Company

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