SPINA BIFIDA
BAB I PENDAHULUAN A.
Latar Belakang
Spina Bifida adalah suatu celah pada tulang belakang (vertebra), yang terjadi karena bagian dari satu atau beberapa vertebra gagal menutup atau gagal terbentuk secara utuh. Gangguan fusi tuba neural terjadi sekitar minggu ketiga setelah konsepsi, sedangkan penyebabnya belum diketahui dengan jelas. Banyak kelainan kongenital yang tidak diketahui penyebabnya. Faktor janinnya sendiri dan faktor lingkungan hidup janin diduga dapat menjadi faktor penyebabnya. Masalah sosial, hipoksia, hipotermia, atau hipertermia diduga dapat menjadi faktor penyebabnya. Seringkali penyebab kelainan kongenitai tidak diketahui. Salah satu kelainan congenital yang sering terjadi adalah spina bifida. Angka kejadiannya adalah 3 di antara 1000 kelahiran. Terjadi karena adanya. Tujuan Penulisan 1.
2. 3. 4. BAB
Mahasiswa Kedokteran dapat menjelaskan definisi Spina Bifida, etiologi Spina Bifida, epidemiologi Spina Bifida, gejala klinis Spina Bifida, patofisiologi Spina Bifida, pemeriksaan fisik Spina Bifida, pemeriksaan penunjang Spina Bifida, penatalaksanaan Spina Bifida, diagnosa Spina Bifida, diagnosis banding Spina Bifida, komplikasi Spina Bifida, Bifida, prognosis Spina Bifida Meningkatkan kemampuan dalam penulisan ilmiah / Makalah di bidang kedokteran. Memenuhi salah satu persyaratan kelulusan Kepaniteraan Klinik Metode tinjauan kepustakaan dengan mengacu kepada beberapa literatur. II
TINJAUAN PUSTAKA A.
Pengertian Spina Bifida
Spina Bifida (Sumbing Tulang Belakang) adalah suatu celah pada tulang belakang (vertebra), yang terjadi karena bagian dari satu atau beberapa vertebra gagal menutup atau gagal terbentuk secara utuh. Keadaan ini biasanya terjadi pada minggu ke empat masa embrio. Spina bifida adalah gagal menutupnya columna vertebralis pada masa perkembangan fetus. Defek ini berhubugan dengan herniasi jaringan dan gangguan fusi tuba neural. Gangguan fusi tuba neural terjadi sekitar minggu ketiga setelah konsepsi, sedangkan penyebabnya belum diketahui dengan jelas. Beberapa hipotesis terjadinya spina bifida antara lain adalah : 1. 2.
Terhentinya proses pembentukan tuba neural karena penyebab tertentu. Adanya tekanan yang berlebih berlebih dikanalis sentralis yang baru terbentuk sehingga sehingga menyebabkan ruptur permukaan tuba neural. 3. Adanya kerusakan pada dinding tuba neural yang baru terbentuk karena suatu penyebab. Spina Bifida (Sumbing Tulang Belakang) adalah suatu celah pada tulang belakang (vertebra), yang terjadi karena bagian dari satu atau beberapa vertebra gagal menutup atau gagal terbentuk secara utuh.
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Etiologi Spina Bifida Resiko melahirkan anak dengan spina bifida berhubungan erat dengan kekurangan asam folat, terutama yang terjadi pada awal kehamilan. Penonjolan dari korda spinalis dan meningens menyebabkan kerusakan pada korda spinalis dan akar saraf, sehingga terjadi penurunan atau gangguan fungsi pada bagian tubuh yang dipersarafi oleh saraf tersebut atau di bagian bawahnya. Gejalanya tergantung kepada letak anatomis dari spina bifida. Kebanyakan terjadi di punggung bagian bawah, yaitu daerah lumbal atau sakral, karena penutupan vertebra di bagian ini terjadi paling akhir Resiko melahirkan anak dengan spina bifida berhubungan erat dengan kekurangan asam folat, terutama yang terjadi pada awal kehamilan. Kelainan bawaan lainnya yang juga ditemukan pada penderita spina bifida, diagnosa banding Spina Bifida : 1. Hidrocephalus 2. Siringomielia 3. Dislokasi pinggul Patofisiologi Spina Bifida
Cacat terbentuk pada trisemester pertama kehamilan, prosesnya karena tidak terbentuknya mesoderm pada daerah tersebut sehingga bagian yang telah menyatu (prosesus nasalis dan maksilaris) pecah kembali. (Media Aesculapius. Kapita Selekta Kedokteran Edisi ke-3 Jilid 2. 2000. Jakarta: MA.) Hidrosefalus seringsepalus empuan 3 kali lebih dominan. pusatsi i foramen Luschkahasilkan peningkatan tekanan dan dilatasi dari aliran proksikali dihubungkan dengan Mielomeningokel yang seharusnya diamati perkembangannya pada bayi. Pada kasus yang masih tersisa terdapat riwayat infeksi intrauterin (toksoplasmosis, sitomegalovirus), perdarahan perinatal (anoksik atau traumatik), dan meningoensepalitis neonatal (bakteri atau virus). Manifestasi Klinik Spina Bifida
Gejalanya bervariasi, tergantung kepada beratnya kerusakan pada korda spinali dan akar saraf yang terkena. Beberapa anak memiliki gejala ringan atau tanpa gejala; sedangkan yang lainnya mengalami kelumpuhan pada daerah yang dipersarafi oleh korda spinalis maupun akar saraf yang terkena. Terdapat beberapa jenis spina bifida: 1.
Spina bifida okulta (tersembunyi) : bila kelainan hanya sedikit, hanya ditandai oleh bintik, tanda lahir merah anggur, atau ditumbuhi rambut dan bila medula spinalis dan meningens normal. 2. Meningokel : bila kelainan tersebut besar, meningen mungkin keluar melalui medula spinalis, membentuk kantung yang dipenuhi dengan CSF. Anak tidak mengalami paralise dan mampu untuk mengembangkan kontrol kandung kemih dan usus. Terdapat kemungkinan terjadinya infeksi bila kantung tersebut robek dan kelainan ini adalah masalah kosmetik sehingga harus dioperasi. 3. Mielomeningokel : jenis spina bifida yang paling berat, dimana sebagian dari medula spinalis turun ke dalam meningokel. Gejalanya berupa:
Penonjolan seperti kantung di punggung tengah sampai bawah pada bayi baru lahir. Jika disinari, kantung tersebut tidak tembus cahaya. Kelumpuhan/kelemahan pada pinggul, tungkai atau kaki. Penurunan sensasi. Inkontinensia urin maupun inkontinensia tinja. Korda spinalis yang terkena rentan terhadap infeksi (meningitis) Pemeriksaan Diagnostik Spina Bifida
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positif palsu yang tinggi, karena itu jika hasilnya positif, perlu dilakukan pemeriksaan lanjutan untuk memperkuat diagnosis. Dilakukan USG yang biasanya dapat menemukan adanya spina bifida.Kadang dilakukan amniosentesis (analisa cairan ketuban). Setelah bayi lahir, dilakukan pemeriksaan berikut: 1. Rontgen tulang belakang untuk menentukan luas dan lokasi kelainan 2. USG tulang belakang bisa menunjukkan adanya kelainan pda korda spinalis maupun vertebra 3. CT scan atau MRI tulang belakang kadang dilakukan untuk menentukan lokasi dan luasnya kelainan. Penatalaksanaan Spina Bifida
Pembedahan dilakukan untuk menutup lubang yang terbentuk dan untuk mengobati hidrosefalus, kelainan ginjal dan kandung kemih serta kelainan bentuk fisik yang sering menyertai spina bifida. Terapi fisik dilakukan agar pergerakan sendi tetap terjaga dan untuk memperkuat fungsi otot. Untuk mengobati atau mencegah meningitis, infeksi saluran kemih dan infeksi lainnya, diberikan antibiotik. Untuk mengatasi gejala muskuloskeletal (otot dan kerangka tubuh) perlu campur tangan dari ortopedi (bedah tulang) maupun terapi fisik. Kelainan saraf lainnya diobati sesuai dengan jenis dan luasnya gangguan fungsi yang terjadi. Kadang pembedahan shunting untuk memperbaiki hidrosefalus akan menyebabkan berkurangnya mielomeningokel secara spontan . Pengobatan Spina Bifida Tujuan dari pengobatan awal Spina Bifida adalah: 1. Mengurangi kerusakan saraf akibat spina bifida 2. Meminimalkan komplikasi (misalnya infeksi) Pembedahan dilakukan untuk menutup lubang yang terbentuk dan untuk mengobati mengobat i hidrosefalus, kelainan ginjal dan kandung kemih serta kelainan bentuk fisik yang sering menyertai spina bifida. Terapi fisik dilakukan agar pergerakan sendi tetap terjaga dan untuk memperkuat fungsi otot. Untuk mengobati atau mencegah meningitis, infeksi saluran kemih dan infeksi lainnya, diberikan antibiotik. Untuk membantu memperlancar aliran air kemih bisa dilakukan penekanan lembut diatas kandung kemih. Diet kaya serat dan program pelatihan buang air besar bisa membantu memperbaiki fungsi saluran pencernaan.
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SPINA BIFIDA Kasus Bayi Ny. V lahir dengan kelainan tulang tulang belakang, dokter mengatakan bayi menderita spina bifida. Definisi Spina Bifida (Sumbing Tulang Belakang) adalah suatu celah pada tulang bel akang (vertebra), yang terjadi karena bagian dari satu atau beberapa vertebra gagal menutup atau gagal terbentuk secara utuh. (http://www.medicastore.com/ http://www.medicastore.com/)) Spina bifida adalah gagal menutupnya columna vertebralis pada masa perkembangan fetus. Defek ini berhubugan dengan herniasi jaringan dan gangguan fusi tuba neural. Gangguan fusi tuba neural terjadi sekitar minggu ketiga setelah konsepsi, sedangkan penyebabnya belum diketahui dengan jelas. Beberapa hipotesis terjadinya spina bifida antara lain adalah :
1. Terhentinya proses pembentukan tuba neural karena penyebab tertentu 2. Adanya tekanan yang berlebih dikanalis sentralis yang baru terbentuk sehingga menyebabkan ruptur permukaan tuba neural 3. Adanya kerusakan pada dinding tuba neural yang baru terbentuk karena suatu penyebab.
( Buku ajar Ilmu Kesehatan Anak, A.H. Markum:2002) Penyebab Resiko melahirkan anak dengan spina bifida berhubungan erat dengan kekurangan asam folat, terutama yang terjadi pada awal kehamilan. Kelainan bawaan lainnya yang juga
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-
Siringomielia
-
Dislokasi pinggul
Beberapa jenis spina bifida :
1. Okulta : merupakan spina bifida yang paling ringan. Satu atau beberapa vertebra tidak terbentuk secara normal, tetapi korda spinalis dan selaputnya (meningens) tidak menonjol.
Gejalanya : -
Seberkas rambut pada daerah sakral (panggul bagian belakang)
-
Lekukan pada daerah sakrum
1. Meningokel : meningens menonjol melalui vertebra yang tidak utuh dan teraba sebagai suatu benjolan dari cairan dibawah kulit.
- menonjolnya meninges - sumsum tulang belakang - cairan serebrospinal
1. Mielokel : jenis spina bifida yang paling berat, dimana korda spinalis menonjol dan kulit diatasnya tampak kasar da merah.
Gejala Gejalanya bervariasi, tergantung kepada beratnya kerusakan pada korda spinalis dan saraf yang terkena. Gejalanya berupa: -
Penonjolan seperti kantung dipunggung tengah sampai bawah pada bayi baru
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-
Kelumpuhan/kelemahan pada pinggul, tungkai atau kaki
-
Penurunan sensasi
-
Inkontinensia urine, maupun inkontinensia tinja
-
Korda spinalis yang terkena, rentan terhadap infeksi (meningitis).
http://images.google.co.id/images Komplikasi Terjadi pada salahsatu syaraf yang terkena dengan menimbulkan suatu kerusakan pada syaraf spinal cord, dengan itu dapat menimbulkan suatu komplikasi tergantung pada syaraf yang rusak. Patofisiologi Cacat terbentuk pada trisemester pertama kehamilan, prosesnya karena tidak terbentuknya mesoderm pada daerah tersebut sehingga bagian yang telah menyatu (prosesus nasalis dan maksilaris) pecah kembali. (Media Ae sculapius. Kapita Selekta Kedokteran Edisi ke-3 Jilid 2. 2000. Jakarta: MA.)
Hidrosefalus seringsepalus empuan 3 kali lebih dominan. pusatsi i foramen Luschkahasilkan peningkatan tekanan dan dilatasi dari aliran proksikali dihubungkan dengan Mielomeningokel yang seharusnya diamati perkembangannya pada bayi. Pada kasus yang masih tersisa terdapat riwayat infeksi intrauterin (toksoplasmosis, sitomegalovirus), perdarahan perinatal (anoksik atau traumatik), dan meningoensepalitis neonatal (bakteri atau virus). Pengobatan Tujuan dari pengobatan awal adalah: -
Mengurangi kerusakan saraf akibat spina bifida
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Pembedahan dilakukan untuk menutup lubang yang terbentuk dan untuk mengobati hidrosefalus, kelainan ginjal dan kandung kemih serta kelainan bentuk fisik yang sering menyertai spina bifida.
Terapi fisik dilakukan agar pergerakan sendi tetap terjaga dan untuk memperkuat fungsi otot.
Untuk mengobati atau mencegah meningitis, infeksi saluran kemih dan infeksi lainnya, diberikan antibiotik.
Untuk membantu memperlancar aliran air kemih bisa dilakukan penekanan lembut diatas kandung kemih.
Diet kaya serat dan program pelatihan buang air besar bisa membantu memperbaiki fungsi saluran pencernaan.
Pencegahan
Resiko terjadinya spina bifida bisa dikurangi dengan mengkonsumsi asam folat.
Kekurangan asam folat pada seorang wanita harus ditangani sebelum wanita tersebut hamil,
karena kelainan ini terjadi sangat dini.
Pada wanita hamil dianjurkan untuk mengkonsumsi asam folat folat sebanyak 0,4 mg/hari. Kebutuhan asam folat pada wanita hamil adalah 1 mg/hari.
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Dengan teknik AFP : hanya membutuhkan sedikit sampel darah dari lengan ibu dan tidak ti dak beresiko terhadap janin. Bila hasil skrining positif biasanya diperlukan test lanjutan untuk memastikan adanya kelainan genetik pada janin yang lahir kelak menderita cacat. -
Pemeriksaan air ketuban ibu
Faktor yang mempengaruhi tumbuh kembang
Faktor genetik
Faktor genetik merupakan dasar dalam mencapai hasil akhir proses tu mbuh kembang anak. Melalui instruksi genetik yang terkandung di dalam sel telur yang telah dibuahi dapat ditentukan kualitas dan kuantitas pertumbuhan. Ditandai dengan intensitas dan kecepatan pembelahan, derajat sensitivitas jaringan terhadap rangsangan, umur pubertas, dan berhentinya pertumbuhan tulang. Termasuk faktor genetik adalah sebagai faktor bawaan yang normal dan patologik, jenis kelamin, suku bangsa,. Potensi genetik yang bermutu jika berinteraksi dengan lingkungan secara positif akan dicapai hasil akhir yang optimal Faktor herediter, sebagai faktor yang sudah dipastikan. 75% dari faktor keturunan resesif dan 25% bersifat dominan. ü
Mutasi gen.
ü
Kelainan kromosom
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fisiko-psiko-sosial” yang me mpengaruhi individu setiap hari mulai dari konsepsi sampai akhir hayat, antara lain :
ü
Faktor usia ibu
ü
Obat-obatan.
Asetosal, Aspirin (SCHARDEIN-1985) Rifampisin, Fenasetin, Sulfonamid, Aminoglikosid, Indometasin, Asam Flufetamat, Ibuprofen, Penisilamin, Antihistamin dapat menyebabkan celah langit-langit. Antineoplastik, Kortikosteroid ü Nutrisi ü Penyakit : infeksi Sifilis, virus virus rubella ü Radiasi ü Stres emosional ü Trauma (trimester pertama)
Faktor psikososial : Respon orang tua terhadap bayi/anak :
ü Rasa bersalah ü Kemampuan membuat membuat keputusan tentang pengobatan/ tindakan segera ü Kemampuan untuk berkomunikasi dengan yang lain Pertumbuhan dan Perkembangan selama masa bayi :
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selama 6 bulan pertama.
telengkup.
-
-
Peningkatan lingkar
kepala sebesar 1,5 cm setiap
Mengalami head lag yang
nyata, khususnya bila menarik
bulan selama 6 bulan pertama. kepala dari posisi berbaring ke -
Ada refleks primitif dan
kuat -
posisi duduk. -
Refleks mata boneka
Menahan kepala sebentar
secara faralel dan dlam garis
dan refleks dansa menghilang. tengah dan tertahan dlam posisi terjadi.
Pernafasan hidung harus telengkup. -
Menunjukan refleks leher
tonik asimetris bila telentang -
Bila menahan dalam posisi
berdiri, tubuh lemas pada lutut dan panggul
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Spina Bifida (kelainan Tulang belakang) Mei 19, 2011
A. Devinisi
Spina Bifida atau Sumbing Tulang Belakang adalah suatu celah pada tulang belakang (vertebra),
yang terjadi karena bagian dari satu atau beberapa vertebra gagal menutup atau gagal terbentuk
secara utuh. ( A.H. Markum )
B. Etiologi
• Kekurangan asam folat pada saat kehamilan
satu gugus yang berperan dalam pembentukan DNA pada proses erithropoesis. Yaitu, dalam
pembentukan sel-sel darah merah atau eritrosit (butir-butir darah merah) dan perkembangan sistem
syaraf.
• Rendahnya kadar vitamin maternal
Rendahnya vitamin maternal yang di konsumsi akan mengurangi vitamin yang dibutuhkan dalam
pembentukan embrio, apa lagi pada awal masa kehamilan, sehingga nutrisi yang dibutuhkan dalam
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Gejalanya :
• Seberkas rambut pada daerah sakral (panggul bagian belakang)
• Lekukan pada daerah sakrum
2. Meningokel
Adalah ketika kantung berisi cairan cerebro-tulang belakang (cairan yang mengelilingi otak dan
sumsum tulang belakang) dan meninges (jaringan yang meliputi sumsum tulang belakang), tidak ada
keterlibatan saraf. meningens menonjol melalui vertebra yang tidak utuh dan teraba sebagai suatu
benjolan dari cairan dibawah kulit.
Gejala :
• menonjolnya meninges
• sumsum tulang belakang
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• Penonjolan seperti kantung dipunggung tengah sampai bawah pada bayi baru lahir
• Jika disinari, kantung tersebut tidak tembus cahaya
• Kelumpuhan/kelemahan pada pinggul, t ungkai atau kaki
• Penurunan sensasi
• Inkontinensia urine, maupun inkontinensia tinja
• Korda spinalis yang terkena, rentan terhadap infeksi (meningitis).
D. Komplokasi
Terjadi pada salah satu syaraf yang terkena dengan menimbulkan suatu kerusakan pada syaraf
spinal cord, dengan itu dapat menimbulkan suatu komplikasi tergantung pada syaraf yang rusak.
• Kejang
• Hidrocephalus
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F. Faktor yang mempengaruhi tumbuh kembang
1. Faktor genetik
Faktor genetik merupakan dasar dalam mencapai hasil akhir proses tumbuh kembang anak. Melalui
instruksi genetik yang terkandung di dalam sel telur yang telah dibuahi dapat ditentukan kualitas dan
kuantitas pertumbuhan. Ditandai dengan intensitas dan kecepatan pembelahan, derajat sensitivitas
jaringan terhadap rangsangan, umur pubertas, dan berhentinya pertumbuhan tulang. T ermasuk faktor
genetik adalah sebagai faktor bawaan yang normal dan patologik, jenis kelamin, suku bangsa,.
Potensi genetik yang bermutu jika berinteraksi dengan lingkungan secara positif akan dicapai hasil
akhir yang optimal
2. Faktor lingkungan
Lingkungan merupakan faktor yang sangat menentukan tercapai atau tidaknya potensi bawaan.
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kelainan ini terjadi sangat dini.
• Pada wanita hamil dianjurkan untuk mengkonsumsi asam folat sebanyak 0,4 mg/hari. Kebutuhan
asam folat pada wanita hamil adalah 1 mg/hari.
H. Pemeriksaan Diagnostik
• USG
Untuk mengetahui apakah ada kelainan spina bifida pada bayi yang dikandung adalah melalui
pemeriksaan USG. Hal itu dapat diketahui ketika usia bayi 20 minggu.
• Pemeriksaan darah pada ibu
Dengan teknik AFP : hanya membutuhkan sedikit sampel darah dari lengan ibu dan tidak beresiko
terhadap janin. Bila hasil skrining positif biasanya diperlukan test lanjutan untuk memastikan adanya
kelainan genetik pada janin yang lahir kelak menderita cacat.
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? Respon terhadap stimulasi
? Kebocoran cairan cerebrospinal
B. Diagnosa Keperawatan
1. Ganguan perfusi jaringan serebral b.d peningkatan tekanan intrakranial
Tujuan :
1. Anak bebas dari infeksi
2. Anak menunjukan respon neurologik yang normal
Kriteria hasil :
? Suhu dan TTV normal
? Luka operasi, insisi bersih
Intervensi Rasional
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• Untuk mencegah terjadinya luka infeksi pada kepala (dekubitus)
• Menghindari terjadinya luka infeksi dan trauma terhadap pemasangan shunt
2. Berduka b.d kelahiran anak dengan spinal malformation
Tujuan :
Orangtua dapat menerima anaknya sebagai bagian dari keluarga
Kriteria hasil :
• Orangtua mendemonstrasikan menerima anaknya dengan menggendong, memberi minum, dan ada
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perpisahan
Tujuan :
Anak mendapat stimulasi perkembangan
Kriteria hasil :
• Bayi / anak berespon terhadap stimulasi yang diberikan
• Bayi / anak tidak menangis berlebihan
• Orangtua dapat melakukan stimulasi perkembangan yang tepat untuk bayi / anaknya
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ASUHAN KEPERAWATAN KEPERAWATAN ANAK DENGAN SPINA SPINA BIFIDA Diposkan oleh Rizki Kurniadi, Amd.Kep
BAB 1 PENDAHULUAN A. Latar Belakang Spina Bifida (Sumbing Tulang Belakang) adalah suatu celah pada tulang belakang (vertebra), yang terjadi karena bagian dari satu atau beberapa vertebra gagal menutup atau gagal terbentuk secara utuh. Gangguan sedangkan
fusi
tuba
neural
terjadi
sekitar
minggu
ketiga
setelah
konsepsi,
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a.Pengertian. Spina Bifida (Sumbing Tulang Belakang) adalah suatu celah pada tulang belakang (vertebra), yang terjadi karena bagian dari satu atau beberapa vertebra gagal menutup atau gagal terbentuk secara utuh. Keadaan ini biasanya terjadi pada minggu ke empat masa embrio.
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dipersarafi oleh saraf tersebut atau di bagian bawahnya. Gejalanya tergantung kepada letak anatomis dari spina bifida. Kebanyakan terjadi di punggung bagian bawah, yaitu daerah lumbal atau sakral, karena penutupan vertebra di bagian ini terjadi paling akhir Resiko melahirkan anak dengan spina bifida berhubungan erat dengan kekurangan asam folat, terutama yang terjadi pada awal kehamilan. Kelainan bawaan lainnya yang juga ditemukan pada penderita spina bifida (diagnosa (diagnosa banding) : 1.
Hidrocephalus
2.
Siringomielia
3.
Dislokasi pinggul c.Patofisiologi Cacat terbentuk pada trisemester pertama kehamilan, prosesnya karena tidak terbentuknya mesoderm pada daerah tersebut sehingga bagian yang telah menyatu (prosesus nasalis dan
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1. Penonjolan seperti kantung di punggung tengah sampai bawah pada bayi baru lahir 2. Jika disinari, kantung tersebut tidak tembus cahaya 3. Kelumpuhan/kelemahan pada pinggul, tungkai atau kaki 4. Penurunan sensasi 5. Inkontinensia urin maupun inkontinensia tinja
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Tujuan dari pengobatan awal adalah: -
Mengurangi kerusakan saraf akibat spina bifida
-
Meminimalkan komplikasi (misalnya infeksi)
Pembedahan dilakukan untuk menutup lubang yang terbentuk dan untuk mengobati
hidrosefalus, kelainan ginjal dan kandung kemih serta kelainan bentuk fisik yang sering menyertai spina bifida.
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4. Risiko tinggi trauma b.d lesi spinal
1. Risiko tinggi infeksi b.d spinal malformation, luka operasi dan shunt Ganguan perfusi jaringan serebral b.d peningkatan tekanan intracranial Intervensi Rasional
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Untuk mencegah terjadinya luka memar dan infeksi yang melebar disekitar luka
4. Risiko tinggi trauma b.d lesi spinal Intervensi Rasional Rawat bayi dengan cermat
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Diharapkan kepada bagi mahasiswa/i dapat menambah wawasan dan pengetahuan khususnya dengan masalah masalah keperawatan tentang tentang penyakit Epilepsidan Epilepsidan juga dapat menerapkannya menerapkannya dalam kehidupan sehari hari.
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Bentuk cacad tabung saraf, tempat kantong selaput otak menonjol melalui mel alui
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berkembang ke samping kemudian sumbu di belakang membentuk tabung
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a. Pada trimester pertama, wanita hamil menjalani pemeriksaan darah yang
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- Pemberian makanan peroral dapat diberikan 4 jam setelah pembedahan.
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