ASKEP KLIEN DG GANGGUAN SISTEM PERKEMIHAN 2

ASKEP KLIEN DG GANGGUAN SISTEM PERKEMIHAN AKIBAT KEGANASANNursiswati, S.Kep.,Ners., M.kep., Sp.KMB

FUNGSI GINJAL :MENGATUR VOLUME CAIRAN TUBUHMENGATUR KES OSMOTIK & MPTHNKN KES ION-ION DL PLASMAMENGATUR KES ASAM BASA CAIRAN TBHEKSRESI ION-ION HSL METABFUNGSI HORMONAL & METABOLISMEPENDAHULUANSTRUKTUR MAKROSKOPIK & MIKROSKOPIK:SEPASANG ORGAN DI BLKG DINDING ABDOMEN, KIRI KANAN KOLUMNA VERTEBRALISTERDIRI ATS :KORTEKS (BAG LUAR)MEDULA (BAG DALAM)TERBNTK O/ JUTAAN NEFRONPEREDARAN DRH : AORTA ABDOMINALIS--ARTERI RENALISBERCABANG KE VENTRAL & DORSALARTERI INTER LOBARISARTERI ARCUATA YG BJALAN DIANTARA KORTEKS & MEDULA.CONTPBTKN URIN:PROSES FILTRASI/ ULTRAFILTRASIDIPENGARUHI O/ PERUB ALIRAN DRH GINJALTEK FILTRASILUAS PERMUKAAN FILTRASIMEMBRAN FILTRASI HANYA DILALUI PLASMA DG GARAM2, GLUKOSA & MOLEKUL KECIL LAINPROSES REABSORBSIPROSES SEKRESICON,TCancer of the kidney accounts for about 3.7% of all cancers inadults in the United States. It affects almost twice as many menas women. The most common type of renal tumor is renal cell orrenal adenocarcinoma, accounting for more than 85% of all kidneytumors (Hock et al., 2002). These tumors may metastasizeearly to the lungs, bone, liver, brain, and contralateral kidney.One third of patients have metastatic disease at the time of diagnosis.The incidence of all stages of kidney cancer has increased

CANCER OF THE KIDNEY

nearly half of all patients with renal cell carcinoma die within 5 years of diagnosis (Pizza, De Vinci, LoConte et al., 2001).Risk Factors for Renal Cancer Gender: Affects men more than women Tobacco use Occupational exposure to industrial chemicals, such as petroleumproducts, heavy metals, and asbestos Obesity Unopposed estrogen therapy Polycystic kidney disease

PD GINJAL TERBAGI MENJADI 2:ADENOKARSINOMAHIPERNEPHROMASTADIUM :I : tumor msh d dl kapsula ginjal & blm menyebar ke vena renalis, jar lemak & limpII : Telah meluas, mlebihi capsul ginjal, blm menyebar k vena renalisIII: telah menyebar luas sampai ke vena renalis & kelj limpIV: menginvasi lbh luas ke bbg organ & metastaseKEGANASAN NYERIHIPERTENSITERABA MASSAPENURUNAN bb PROGRESIFDEMAMMANIFESTASIClinical ManifestationsMany renal tumors produce no symptoms and are discovered ona routine physical examination as a palpable abdominal mass.The classic triad of signs and symptoms, which occurs in only10% of patients, comprises hematuria, pain, and a mass in theflank. The usual sign that first calls attention to the tumor is painless hematuria, which may be either intermittent and microscopic or continuous and gross. There may be a dull pain in the back from the pressure produced by compression of the ureter, extension of the tumor into the perirenal area, or hemorrhage into the kidney tissue. Colicky pains occur if a clot or mass of tumor cellspasses down the ureter. Symptoms from metastasis may be thefirst manifestations of renal tumor and may include unexplainedweight loss, increasing weakness, and anemia.

ARTERIOGRAFI : DRJT PENYEBARANIVP : MASSA DL GINJALCt-scan : MASSA YG MENGELILINGI GINJALLAB : Urinalisis, hematologiPEM DIAGNOSTIKRIW KES KLIENRIW KES KLGPEM FISIKDATA PSIKOLOGISPENGKAJIANGGN RS NYAMAN : NYERI B.D DESAKAN DR SEL2 KARSINOMAGGN PEMENUHAN NUTRISI KURANG DR KEBUT TBH B.D PENINGKATAN METABOLISMEGGN RS AMAN:CEMAS B.D PERSEPSI INDIV YG SALAH THD PENYAKITNYTA DIAGNOSA KEPNON SURGICAL : CHEMOTERAPISURGICAL RADIKAL NEPHRECTOMYTINDAKAN KHUSUSThe goal of management is to eradicate the tumor before metastasis occurs (Kirkali, Tuzel & Munga, 2002).

MEDICAL MANAGEMENT

DITUJUKAN PD :PBERIAN PENKESMENGAJARKN NFS DLMLAT MOB AKTIF-PASIF MCEGAH KOMPLIKASIMBERI MOTIVASI U MMNH KEBUT RS AMANKOLAB ANALGETIK, ANTIPIRETIK, OR SEDATIFPERAWATAN PRE OP OBSERVASI; DISTENSI AKBT PERDARAHANOBSERVASI INTAKE OUTPUT, TK KESAD, TTVMEMPERLANCAR VENTILASIMONITOR TANDA SHOCKCGH KOMPLIKASIOBAT-OBATANPOST OPAfter surgery, the patient usually has catheters and drains in place to maintain a patent urinary tract, to remove drainage, and to permit accurate measurement of urine output. Because of the location of the surgical incision, the position of the patient during surgery, and the nature of the surgical procedure, pain and muscle soreness are common.The patient requires frequent analgesia during the postoperative period and assistance with turning. Turning, coughing, use of incentive spirometry, and deep breathing are encouraged to prevent atelectasis and other pulmonary complications. The patientand family require assistance and support to cope with the diagnosis and uncertainties about the prognosis. The patient is encouraged to eat a well-balanced diet and to drink adequate liquids to avoid constipation and to maintain an adequate urine volume. Education and emotional support are providedrelated to the disease process, treatment plan, and continuing care because many patients are concerned about the loss of the other kidney, the possible need for dialysis, or the recurrence of cancer.Continuing Care. Follow-up care is essential to detect signs of metastases and to reassure the patient and family about the patients status and well-being. The patient who has had surgery for renal carcinoma should have a yearly physical examination and chest x-ray because late metastases are not uncommon. All subsequent symptoms should be evaluated with possible metastases in mind.

If follow-up chemotherapy is necessary, the patient and family are informed about the entire treatment plan or chemotherapy protocol, what to expect with each visit, and how to notify the physician. Periodic evaluation of remaining renal function (creatinine clearance, serum BUN and creatinine levels) may also be carried out periodically. A home care nurse may monitor thepatients physical status and psychological well-being and coordinate other services and resources needed by the patient.

Cancer of the urinary bladder is more common in people aged50 to 70 years. It affects men more than women (3:1) and is more common in whites than in African Americans. Bladder cancer is the fourth leading cause of cancer in American men, accounting for more than 12,000 deaths in the U.S. annually (American Cancer Society, 2002). Bladder cancer has a high worldwide incidence(Amling, 2001). Bladder tumors account for nearly 1 in 25 cancers diagnosed in the United States.CA BLADDERThere are two forms of bladder cancer: superficial (which tends to recur) and invasive.About 80% to 90% of all bladder cancers are transitional cell (which means they arise from the transitional cells of the bladder);the remaining types of tumors are squamous cell and adenocarcinoma.Research has demonstrated that many individuals with bladder cancer for which a total cystectomy is required go on to develop upper urinary tract tumors (Amling, 2001; Huguet-Perez, Palui, Millan-Rodriguez et al., 2001).The predominant cause of bladder cancer today is cigarette smoking. Cancers arising from the prostate, colon, and rectum in males and from the lower gynecologic tract in females may metastasize to the bladder Cigarette smoking: risk proportional to number of packssmoked daily and number of years of smoking Environmental carcinogens: dyes, rubber, leather, ink, or paint Recurrent or chronic bacterial infection of the urinary tract Bladder stones High urinary pH High cholesterol intake Pelvic radiation therapy Cancers arising from the prostate, colon, and rectum in malesRisk Factors for Bladder Cancer

Clinical ManifestationsBladder tumors usually arise at the base of the bladder and involve the ureteral orifices and bladder neck. Visible, painless hematuria is the most common symptom of bladder cancer. Infection of the urinary tract is a common complication, producing frequency,urgency, and dysuria. Any alteration in voiding or change in the urine, however, may indicate cancer of the bladder. Pelvic or back pain may occur with metastasis.cystoscopy (the mainstay of diagnosis), excretory urography, a CT scan, ultrasonography, and bimanual examination with the patient anesthetized. Biopsies of the tumor and adjacent mucosa are the definitive diagnostic procedures.Transitional cell carcinomas and carcinomas in situ shed recognizable cancer cells. Cytologic examination of fresh urine and saline bladder washings provide information about the prognosis, especially for patients at high risk for recurrence of primary bladder tumors (Amling, 2001).The diagnostic evaluation includes :Although mainstay diagnostic tools such as cytology and CT scanning have a high detection rate, they are costly. Newer diagnostic indicators are being studied. Bladder tumor antigens, nuclear matrix proteins, adhesion molecules, cytoskeletal proteins,and growth factors are being studied to support the early detectionand diagnosis of bladder cancer. There are an increasing number of molecular assays available for the detection of bladder cancer (Saad, Hanbury, McNicholas et al., 2001).

Treatment of bladder cancer depends on the grade of the tumor(the degree of cellular differentiation), the stage of tumor growth(the degree of local invasion and the presence or absence of metastasis),and the multicentricity (having many centers) of thetumor. The patients age and physical, mental, and emotional statusare considered when determining treatment modalities.

Medical ManagementSURGICAL MANAGEMENTTransurethral resection or fulguration (cauterization) may be performedfor simple papillomas (benign epithelial tumors). surgical incision or electrical current with the useof instruments inserted through the urethra. After this bladdersparingsurgery, intravesical administration of BCG is the treatment of choice.Management of superficial bladder cancers presents a challengebecause there are usually widespread abnormalities in the bladdermucosa. The entire lining of the urinary tract, or urothelium, is at risk because carcinomatous changes can occur in the mucosa ofthe bladder, renal pelvis, ureter, and urethra. About 25% to 40% of superficial tumors recur after transurethral resection or fulguration.Patients with benign papillomas should undergo cytology and cystoscopy periodically for the rest of their lives because aggressivemalignancies may develop from these tumors.

A simple cystectomy (removal of the bladder) or a radicalcystectomy is performed for invasive or multifocal bladder cancer.Radical cystectomy in men involves removal of the bladder, prostate, and seminal vesicles and immediate adjacent perivesical tissues. In women, radical cystectomy involves removal of the bladder, lower ureter, uterus, fallopian tubes, ovaries, anterior vagina, and urethra. It may include removal of pelvic lymph nodes. Removal of the bladder requires a urinary diversion procedure.

Although radical cystectomy remains the standard of care forinvasive bladder cancer in the United States, researchers are exploring trimodality therapy: transurethral resection of the bladder tumor, radiation, and chemotherapy. This is in an effort to spare patients the need for cystectomy. A trimodality approach to transitional cell bladder cancer mandates lifelong surveillancewith cystoscopy. Although most completely responding patients retain their bladders free from invasive relapse, one quarter develop superficial disease. This may be managed with transurethral resection of the bladder tumor and intravesical therapies but carries an additional risk that late cystectomy will be required (Zietman, Grocela & Zehr, 2001; Zietman, Shipley & Kaufman, 2000).

Preoperative Nursing DiagnosesBased on the assessment data, the preoperative nursing diagnosesfor the patient undergoing urinary diversion surgery may includethe following: Anxiety related to anticipated losses associated with the surgicalprocedure Imbalanced nutrition, less than body requirements relatedto inadequate nutritional intake Deficient knowledge about the surgical procedure and postoperativecare

Postoperative DiagnosisNURSING DIAGNOSESBased on the assessment data, the major postoperative nursing diagnoses for the patient following urinary diversion surgery may include the following: Risk for impaired skin integrity related to problems in managing the urine collection appliance Acute pain related to surgical incision Disturbed body image related to urinary diversion Potential for sexual dysfunction related to structural and physiologic alterations Deficient knowledge about management of urinary function

In the immediate postoperative period, urine volumes are monitoredhourly. An output below 30 mL/h may indicate dehydrationor an obstruction in the ileal conduit, with possible backflow orleakage from the ureteroileal anastomosis. Throughout the patientshospitalization, the nurse monitors closely for complications, reportssigns and symptoms of them promptly, and intervenesquickly to prevent their progression.

NURSING CONSIDERATIONPROMOTING URINE OUTPUTA catheter may be inserted through the urinary conduit if prescribedto monitor the patient for possible stasis or residual urinefrom a constricted stoma. Urine may drain through the bilateralureteral stents as well as around the stents. If the ureteral stentsare not draining, the nurse may be instructed to irrigate themwith 5 to 10 mL of sterile normal saline solution. It is importantto avoid any tension on the stents because this may dislodgethem. Hematuria may be noted in the first 48 hours after surgerybut usually resolves spontaneously.

PROVIDING STOMA AND SKIN CAREBecause the patient requires specialized care, a consultation is initiatedwith an enterostomal therapist or clinical nurse specialist inskin care. The stoma is inspected frequently for color and viability.A healthy stoma is beefy red. A change from this normal colorto a dark purplish color suggests that the vascular supply may becompromised. If cyanosis and a compromised blood supply persist,surgical intervention may be necessary. The stoma is not sensitiveto touch, but the skin around the stoma becomes sensitive ifurine or the appliance irritates it. The skin is inspected for (1) signsof irritation and bleeding of the stomal mucosa, (2) encrustationand skin irritation around the stoma (from alkaline urine comingin contact with exposed skin), and (3) wound infections.

TESTING URINE AND CARING FOR THE OSTOMYMoisture in bed linens or clothing or the odor of urine aroundthe patient should alert the nurse to the possibility of leakagefrom the appliance, potential infection, or a problem in hygienicmanagement. Because severe alkaline encrustation can accumulaterapidly around the stoma, the urine pH is kept below 6.5 byadministration of ascorbic acid by mouth. Urine pH can be determinedby testing the urine draining from the stoma, not fromthe collecting applianceENCOURAGING FLUIDS AND RELIEVING ANXIETYBecause mucous membrane is used in forming the conduit, thepatient may excrete a large amount of mucus mixed with urine.This causes many patients to feel anxious. To help relieve thisanxiety, the nurse reassures the patient that this is a normal occurrenceafter an ileal conduit procedure. The nurse encouragesadequate fluid intake to flush the ileal conduit and decrease theaccumulation of mucus.

SELECTING THE OSTOMY APPLIANCEVarious urine collection appliances are available, and the nurse isinstrumental in selecting an appropriate one. The urinary appliancemay consist of one or two pieces and may be disposable (usuallyused once and discarded) or reusable. The choice of applianceis determined by the location of the stoma and by the patientsnormal activity, manual dexterity, visual function, body build,economic resources, and preference.

PROMOTING HOME AND COMMUNITY-BASED CARETeaching Patients Self-Care. Patient education begins in thehospital but continues into the home setting because patients areusually discharged within days of surgery. The nurse teaches thepatient how to assess and manage the urinary diversion as well ashow to deal with body image changes. An enterostomal therapistis invaluable in consulting with the nurse on various aspects ofcare and patient education.

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