KDM_Kebutuhan Eliminasi copy........pptx

Editor's Notes

• #4: pola kebiasaan eliminasi. Meliputi frekuensi dan waktu. Kaji adanya inkontinensia feses, konstipasi, diare Kaji dan deskripsikan karakteristik feses. Menetukan apakah feses biasanya cair (diare), atau berbentuk lunak, keras, kaji warna feses, dan adanya darah (contohnya kaji adanya hematokezia atau melena). Meminta klien untuk menggambarkan bentuk feses dan jumlah per harinya. Kaji apakah adanya penggunaan obat-obatan yang membantu elimansi klien seperti enema, obat pencahar, atau makanan tambahan dalam membant pergerakan kebiasaan sebelum eliminasi, serta kaji seberapa sering pasien menggunakannya Kaji adanya status pengalihan elimanasi usus,. Kaji apakah klien memiliki ostomy,nilai frekuensi drainase feses, karakter feses, tampilan dan kondisi stoma (warna, bengkak, dan iritasi), jenis perangkat pengumpulan feses yang digunakan, dan metode digunakan untuk mempertahankan fungsi ostomy tersebut
• #5: pengkajian perubahan pola makan dan perubahan berat badan (jumlah kehilangan atau kenaikan). Jika perubahan berat badan ada,tanyakan apakah hal tersebut direncanakan (misalnya, berat hilang dengan diet) Riwayat Diet. Tentukan preferensi makanan klien untuk satu hari. Tentukan asupan buah-buahan, sayuran, sereal, dan roti dan waktu makan yang teratur atau tidak teratur. Deskripsi asupan cairan harian. Kaji termasuk jenis dan jumlah cairan. Kaji riwayat operasi atau penyakit yang mempengaruhi saluran pencernaan: Informasi ini membantu menjelaskan gejala, potensi untuk menjaga atau memulihkan pola eliminasi usus normal, dan apakah ada riwayat keluarga kanker GI. Riwayat pengobatan: Tanyakan apakah klien konsumsi obat (misalnya, obat pencahar, antasida, suplemen zat besi, dan analgesik) yang mengubah buang air besar atau karakteristik tinja. Serta tanyakan adanya riwayat alergi. Emosi klien secara signifikan mengubah dapat frekuensi buang air besar. Selama pengamatan penilaian emosi klien, nada suara, dan tingkah laku mengungkapkan perilaku yang signifikan yang menunjukkan stres.
• #7: Jaundice: Liver disease. Redness: Inflammation. Cyanosis: Hypoxia. ¦ ¦ Skin color should be consistent with patient’s ethnicity. Color may be lighter on abdomen than on other areas of body because of lack of sun exposure. Skin color should be the same throughout the abdomen. Abdominal skin intact with no lesions or masses. Striae may be present. If new, should be pink; if old, white/silver. In a pregnant patient, striae and linea nigra may be present. Linea nigra ABNORMAL FINDINGS/RATIONALE Bluish discoloration around umbilicus (Cullen’s sign): Hemorrhagic pancreatitis or intraperitoneal bleeding. Discoloration of lower abdominal flanks and lower back (Grey-Turner’s sign): Pancreatitis or extraperitoneal bleeding. Bruises: Recent trauma. Pink-purple striae: Cushing’s syndrome. Spider angioma: Liver failure. Caput medusa (dilated veins that extend from the umbilicus): Liver failure Hernias (protrusion of abdominal organs through opening in abdominal wall): Caused by weakness of abdominal muscles. Seen as bulges that occur when patient bears down. Occur on old surgical incisions, around umbilicus, or in inguinal area. Epigastric or linea alba hernias occur when intestine protrudes through opening in midline of abdomen above umbilicus. Diastasis recti (separation of rectus abdominis muscle that occurs in linea alba): Occurs in pregnant women and newborns. Dermatomally distributed vesicular rash on lower rib cage in upper quadrants: Herpes zoster.
• #9: HELPFUL HINT Listen over the ileocecal valve in the RLQ to the right of the umbilicus. This is normally a very active area connecting the small intestine to the large intestine. Auscultating the abdomen ABNORMAL FINDINGS/RATIONALE Bowel sounds more than 30 clicks (bowel sounds)/min: Hyperactive bowel sounds or hyperperistalsis. Causes include irritable bowel disease, bowel infection, early bowel obstruction, diarrhea, resolving paralytic ileus, or laxative use. Types of hyperperistalsis include: ¦ ¦ Borborygmi, which may be audible without a stethoscope and are characterized by a long stomach “gurgling.” Succussion splash, a loud sound like splashing water, is often heard without a stethoscope as the patient moves from side to side. It occurs when the abdomen is filled with air or fluid and indicates delayed gastric emptying from an obstruction or gastric dilatation. Bowel sounds less than 5 clicks/min but present: Hypoactive or hypoperistalsis. Causes include peritonitis, medications such as opioids, bowel obstruction, or postoperative occurrence. Absent bowel sounds are caused by late bowel obstruction, peritonitis, or paralytic ileus after surgery during which the bowel was manipulated
• #11: xtremely high-pitched tympanic sounds: Distension. Extensive dullness: Organ enlargement or underlying mass.
• #12: Involuntary guarding and rigidity: Peritonitis. Areas of tenderness: Indicates underlying problem. Masses: May indicate underlying tumor, enlarged uterus, feces-filled colon. Enlarged liver: May indicate cirrhosis, tumor, hepatitis. Enlarged spleen: May indicate malignancy, infection, trauma to spleen.
• #30: Loop ileostomy is most often used for relief as it is an easy operation method and easy to put back.
• #32: Sutures on the everted stoma will be removed app. 10 days post-op. The Ostomy is not sutured in the underlying layers