TUGAS INDIVIDU
ASUHAN KEPERAWATN GANGGUAN SISTEM HEMATOLOGY “PROSEDUR TINDAKAN KHUSUS PADA GANGGUAN HEMATOLOGY”
DOSEN: N G Susantie Makabori, S.Kep, Ns. M.Kes
Oleh
Nama
: Ni Putu Dettyasari Dewi
NIM
: PO.71.21.1.3.08.52
Tingkat
: IIB
DAPARTEMEN KESEHATAN REPUBLIK INDONESIA POLITEKNIK KESEHATAN JAYA PURA PROGRAM STUDI D-III KEPERAWATAN MANOKWARI TAHUN AKADEMIK 2009
1
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KATA PENGANTAR Puji syukur penulis panjatkan kehadirat Tuhan Yang Maha Esa karena atas berkat dan rahmat rahmatNya Nya penuli penuliss dapat dapat menyel menyelesa esaika ikan n penyus penyusuna unan n makalah makalah ini, ini, yaitu yaitu tentan tentang g Prosedur Prosedur Tindakan Tindakan Khusus Khusus Pada Gangguan Gangguan Hematolog Hematology y sehingga sehingga dapat berguna berguna bagi mahasiswa/i Program Studi DIII Keperawatan Manokwari angkatan ke-4 Tahun Akademik 2009/2010.
Ucapan terimakasih tak lupa penulis ucapkan kepada Dosen mata kuliah Asuhan Keperawatan pasa Sistem Hematology Ibu N G Susantie Makabori, S.Kep, Ns.
yang telah telah membim membimbin bing g dan mengar mengarahk ahkan an Penuli Penulis, s, sehing sehingga ga makala makalah h yang yang M.Kes yang membah membahas as tentan tentang g “ Prosed Prosedur ur Tindak Tindakan an Khusus Khusus Pada Pada Ganggu Gangguan an Hemato Hematolog logy” y” dapat dapat terselesaikan dengan baik.
Penu Penuli lisa san n maka makala lah h ini ini memb membah ahas as tent tentan ang g Pros Prosed edur ur Umum Umum Tind Tindak akan an pad pad a Gangguan Gangguan hematologi. hematologi. Kemudian Kemudian menyertakan menyertakan suatu penyakit penyakit perdarahan perdarahan yang terjadi pad padaa otak otak seba sebaga gaii acua acuana naga garr penu penuli liss dapa dapatt memb membah ahas as tent tentna nag g tind tindak akan an khus khusus us penanganannya.
Penulis menyadari sepenuhnya bahwa penyusunan makalah ini masih jauh dari kesempurnaan, oleh sebab itu penulis mengharapkan dan menerima kritik dan saran yang membangun dari pembaca, untuk menyempurnakan isi makalah ini.
Akhirnya Akhirnya semoga materi ini dapat bermanfaat bermanfaat bagi upaya peningkata peningkatan n Sumber Sumber Daya Kesehatan di Lingkungan Kabupaten Manokwari Propinsi Papua Barat khususnya bagi Para mahasiswa/i Program Studi D III Keperawatan Manokwari.
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Daftar isi Halaman
Halaman judul...................................................................................................... 1 Kata pengantar.................................................................................................. ..
2
Daftar isi.............................................................................................................. 3
Bab
I
Pendahuluan.............................................................................................. 5 1.1.
Latar
Belakang..................................................................................... 5 1.2.
Rumusan
Masalah............................................................................... 6 1.3.
Tujuan
Penulisan................................................................................. 6 1.4.
Metode
Penulisan............................................................................... 7
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Bab
II
Pembahasan.............................................................................................. .
8 2.1
Produser
tindakan
hemetologi.....................
umum
pada
sistem
8
2.1.1
Biopsi
sum-sum
tulang....................................................... tulang....................................... ................ 8 2.1.2
Pungsi
sum-sum
tulang....................................................... tulang....................................... ................ 9 2.1.3
Pungsi
vena...... vena............ ............ ............ ............ ............ ............ ............ ............ ........... ........... ............ ........ ..
12
2.1.4 Flebotom Flebotomi... i......... ............ ............ ............ ............ ............ ............ ............ ............ ............ ........... ........... ........ .. 12 2.2
Pendarahan
Intra
Nontr ntraum aumati atik... k..... .... .... ........ ...... .... .... .... .... .... .... ........ ...... .... 2.2.1
selebral
15
Pengelolahan
medik edik .... ...... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... Penilaian
secara
17
dan
pengelolaan
inisial inisial..... ........... ............ ............ ............ ............ ........ 17 Pencegahan
perdarahan
ulang ang.......................... ......... ..........
18
Mengurangi
efek
mass massa. a... .... .... .... .... .... .... .... .... .... .... ..... ..... .... .... .... .... .... .... .... ..... ..... ..... ...
19
Perawatan umum umum.. .... .... .... .... .... ..... ..... ..... ..... .... .... .... .... .... .... .... ..... ..... ..... ..... .... .... .... .... ..... ..... ..
20
Pemeriksaan lain............................................................21 2.2.2
Pengelolaan
bed bedah.. ah.... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... Indikasi
secara 21
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Lokasi dan ukuran perdarahan hipertensif.................... 23 Status klin klinis is.. .... .... .... .... .... .... .... ..... ..... .... .... .... .... .... .... .... ..... ..... ..... ..... .... .... .... .... ..... ..... ..... ..... .... .... .... Saat oper operas asi. i... .... .... .... .... .... .... .... .... .... .... ..... ..... ..... ..... .... .... .... .... .... .... .... .... ..
25 melakukan
25
Bab
III
Penutup................................................................................................. 26 3.1
Kesimpul Kesimpulan... an........ ........... ............ ............ ............ ............ ........... ........... ............ ............ ............ ............ .......... .... ..
3.2
26
Saran.... Saran.......... ........... ........... ........... ........... ............ ............ ........... ........... ............ ............ ........... ........... ............ ......... ... .
26
Daftar pustaka................................................................................................. 27
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BAB I PENDAHULUAN
1.1 Latar belakang belakang Kelainan Kelainan Perdarahan Perdarahan ditandai ditandai dengan dengan kecenderun kecenderungan gan untuk untuk mudah mudah mengalami mengalami perdarahan, yang bisa terjadi akibat kelainan pada pembuluh darah maupun kelainan pada darah. Kelainan yang terjadi bisa ditemukan pada faktor pembekuan darah< atau trombosit. Dalam keadaan normal, darah terdapat di dalam pembuluh darah (arteri, kapiler dan vena). Jika terjadi perdarahan, darah keluar dari pembuluh darah tersebut, baik ke dalam maupun ke luar tubuh. Tubuh mencegah atau mengendalikan perdarahan melalui beberapa cara. Homeos Homeostati tatiss adalah adalah cara tubuh tubuh untuk untuk mengen mengentik tikan an perdar perdaraha ahan n pada pada pembul pembuluh uh darah yang mengalami cedera. Hal ini melibatkan 3 proses utama: 1. Konstr Konstriks iksii (pengke (pengkerut rutan) an) pembu pembuluh luh darah darah 2. Aktivitas Aktivitas trombosit trombosit (partikel (partikel berbentu berbentuk k seperti sel sel yang tidak tidak teratur, teratur, yang terdapat terdapat di dalam darah dan ikut serta dalam proses pembekuan) 3. Aktivitas Aktivitas faktor-fak faktor-faktor tor pembekuan pembekuan darah darah (protein (protein yang yang terlarut terlarut dalam dalam plasma). plasma). Kelainan pada proses ini bisa menyebabkan perdarahan ataupun pembekuan yang berlebihan, dan keduanya bisa berakibat fatal.
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otak otak dapat dapat menim menimbul bulkan kan penngg pennggian ian TIK. TIK. Dilai Dilain n fihak fihak penin peninggi ggian an TIK mempuny mempunyai ai konsekuen konsekuensi si yang buruk buruk terhadap terhadap outcome pasien. pasien. Jadi pening peninggia gian n TIK tidak tidak hanya hanya menunj menunjukk ukkan an adany adanya a masal masalah, ah, namun namun seri sering ng
bert bertan angg ggun ungg-ja jawa wab b
terh terhad adap apny nya. a.
Mass Massa a
bers bersam ama a
edem edema a
sekita sekitarny rnya, a, serta serta hidros hidrosefa efalu lus s obstru obstrukti ktiff yang yang diaki diakibat batkan kannya nya,, akan akan meninggikan TIK dan juga akan mendistorsikan jaringan otak. Pada Pada saat saat sutura sutura tengko tengkorak rak telah telah berfus berfusi, i, volum volume e intra intra krani kranial al kons konsta tan. n. Isi Isi intr intrak akra rani nial al utam utama a adal adalah ah otak otak,, dara darah, h, sert serta a cair cairan an serebrospinal yang masing-masing tidak dapat diperas. Karenanya bila volume salah satu berubah, akan terjadi peninggian TIK kecuali biala terjadi reduksi yang bersamaan dan ekual dari volume lainnya. Selama fase fase komp kompen ensa sasi si,, terj terjad adii peng pengga gant ntia ian n volu volume me yang yang hamp hampir ir ekua ekuall sehin sehingga gga sedik sedikit it saja saja peruba perubahan han pada pada TIK. TIK. Pada Pada titik titik dekom dekompen pensas sasi, i, peni pening nggi gian an
volu volume me
sela selanj njut utny nya a
akan akan
meny menyeb ebab abka kan n
pena penamb mbah ahan an
tekanan yang makin makin besar. Peruba Perubahan han volum volume e sendi sendiri ri bersif bersifat at penjum penjumlah lahan. an. Efek Efek massa massa patologis akan sangat membesar oleh adanya edema sekitarnya. Pada kasus yang lebih kompleks juga karena gangguan absorbsi CSS akibat perdaraha perdarahan n subarakhn subarakhnoid oid atau perdarahan perdarahan intra intra ventrikul ventrikuler. er. Mungkin Mungkin juga dapat juga ditambahkan vasodilatasi vasodilatasi akibat akibat hilangnya autoregulasi autoregulasi atau hiperkarbia. Efek Efek klinis klinis tingka tingkatt penin peninggi ggian an terten tertentu tu TIK sangat sangat bervar bervarias iasi. i. Pe
ebab ebab akhi akhi
ke
la
otak otak adal adalah ah iske iskemi mi
Ka
tuk tuk
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arteri arterial, al, TIK, TIK, autor autoregu egulas lasi, i, sti stimu mulas lasii metabo metabolik lik,, serta serta dis distor torsi si atau atau kompressi pembuluh darah oleh massa intrakranial atau oleh herniasi yang yang
lang langsu sung ng
meru merusa sak k
kapa kapasi sita tas s
auto autore regu gula lasi si,,
meny menyeb ebab abka kan n
bendungan vena atau iskemia akibat kompressi arteria. 1.2 Rumusan Rumusan Masalah Masalah Adapun rumusan masalah dari makalah ini yaitu 1. Bagaimana Bagaimana prosedu prosedurr tidakan tidakan pada gangguan gangguan siste, siste,m m hematolog hematology y itu? 2. Penang Penangana anan n apa saja saja yang yang si perluk perlukan an saat terjadi terjadi tekanan tekanan intrakra intrakrania niall pada pada otak yang dimana dalam makalah ini penulis mengambil kasus Perdarahan Intraserebral Nontraumatik?
1.3 Tujuan Tujuan Penulisan Penulisan Tujuan Tujuan dari dari pembu pembuatan atan makala makalah h ini agar agar Mahasi Mahasiswa swa Akper Akper dapat dapat menget mengetahu ahuii pros prosedu edurr tindak tindakan an apa saja saja yang yang dapat dapat dan biasan biasanya ya dilaku dilakukan kan pada pada pasien pasien dengan dengan gangguan Sistem Hematology. 1.4 Metode Penulisan Penulisan Adapun metode penulisan yang penulis gunakan adalah mengambil sumber dari buku dan internet.
1.5 Sistematika Sistematika Penulisa Penulisan n Untuk memudahkan memudahkan pebaca dalam memahami memahami isi makalah ini maka penulis penulis membuat suatu sistematika penulisan yaitu sebagai berikut Bab Bab I Pend Pendah ahul ulua uan, n, terd terdir irii dari dari Latar Latar bela belaka kang ng,, Rumu Rumusa san n masa masalah lah,, Tuju Tujuan an penulisan, Metode penulisan, dan Sitematika penulisan
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BAB II PEMBAHASAN
2.1 PROSED PROSEDUR UR TINDAK TINDAKAN AN UMUM UMUM / PEMERI PEMERIKSAA KSAAN N DIAGNO DIAGNOSTIK STIK PADA PADA SISTEM HEMATOLOGI
2.1.1 Biopsi Sumsum Tulang Biopsi Biopsi sumsum sumsum tulang tulang merupaka merupakan n metode metode pemeriks pemeriksaan aan sistem sistem hematology dengan cara mengambil sedikit jaringan yang berada pada
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Kecu Kecuri riga gaan an adan adanya ya gang ganggu guan an sel sel dara darah h dan dan mene menent ntuk ukan an stad stadiu ium m keganasan non-hematology. non-hematology. ♣
KONTRAINDIKASI
Kontraindikasi Kontraindikasi dari prosedur ini adalah sebagai berikut: 1. Tidak Tidak ada ada kontra kontraindi indikasi kasi mutlak mutlak 2. Pad Pada
Trom Trombo bosi sito tope peni nia a
bera beratt
(<20 (<20.0 .000 00))
pemb pember eria ian n
tran tranfu fusi si
trombosit trombosit sebelumtindakan akan lebih baik 3. Melakukan Melakukan biopsi biopsi sum-s sum-sum um tulang tulang pada sternu sternum m ♣
PERSIAPAN
Persiapan yang dilakukan adalah sebagai berikut Bahan dan Alat 1. Jaru Jarum m bio biops psii 2. Perl Perlen engk gkap apan an stan standa darr mino minorr set set sede sederh rhan ana, a, yait yaitu: u: anti antise sept ptik ik,, alkohol 70%, kapas lidi, duk berlubang, spuit 5 cc, lidokain, sarung tangan steril, kasa steril, plester, botol kaca dan formalin 10%.
♣
PROSEDUR TINDAKAN
Cara Cara mela melaku kuka kan n tind tindaka akan n biop biopsi si su summ-su sum m tula tulang ng adal adalah ah seba sebaga gaii berikut. 1. Klie Klien n dimi dimint nta a untu untuk k buan buang g air air besa besar/ r/ke keci cill sebe sebelu lum m tind tindak akan an dimulai 2. Posisikan Posisikan klien klien pada posisi posisi tengkur tengkurap ap 3. Cuci Cuci tang tangan an
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9. Sunt untikan kan
jarum arum biopsi opsi
deng engn
cara ara
twis wisting ting morion
sam sambil
mela melaku kuka kan n pene peneka kana nan n samp sampai ai tera terasa sa mene menemb mbus us tula tulang ng dan dan dilanjutkan sepanjang 1-2 cm 10 .
Melakukan gerakan empat arah (atas, bawah, kiri, dan
kanan), setelah itu angkat jarumnya 11 .
Luka bi biopsi di ditutup
kasa st steril ya yang d diibasahi po povidone
iodine dan di tutup dengan kasa kering kemudian di plaster dan tidak boleh dibasahi selama 3 hari 12 .
Rapikan klien
13 .
Cuci tangan
♣
KOMPLIKASI
Posedur ini dapat mengakibatkan terjadinya terjadinya perdarahan dan infeksi.
2.1.2 PUNGSI SUM-SUM SUM-SUM TULANG TULANG Pungsi Pungsi sum-sum sum-sum tulang tulang merupakan merupakan tindakan tindakan pengambil pengambilan an sedikit sedikit cairan sum-sum tulang. ♣
TUJUAN
Tujuan dari pungsi sum-sum tulang adalah sebagai berikut 1. Penilain Penilainan an terhadap terhadap simpanan simpanan zat besi besi 2. Mend Mendap apat atka kan n
spes sp esim imen en
untu untuk k
peme pemeri riks ksaa aan n
Bakt Bakter erio iovi viro rolo logi gis s
(biakan mikrobiologi) 3. Diag Diagno nosi sis s sito sitomo morf rfol olog ogy/ y/ev eval alua uasi si prod produk uk pema pemata tang ngan an sel sel asal asal darah ♣
INDIKASI
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1. Bahan Bahan tinda tindakan kan anti antisep septik tik 2. Povi Povido done ne Iod Iodin ine e 3. Kapas Kapas lidi lidi steri sterill dan kapas kapas steril steril 4. Prok Prokai ain/ n/li lido doka kain in 3% dan dan sp spui uitt 5 cc, cc, sp spui uitt 20 cc, cc, sert serta a jaru jarum m hipodermik hipodermik 23-25 gaus. 5. Sarung Sarung tangan tangan steril steril dan duk berlub berlubang ang yang steril steril 6. Zar jarum jarum ampirasi ampirasi sum-sum sum-sum tulang tulang (14-16) (14-16) yang sesuai sesuai dengan dengan tempat yang akan dilakukan dan spuit yang sesuai dengan jarum aspirasi sumsum tulang 7. Boto Botoll bers bersih ih untu untuk k kole koleks ksii aspi aspira ratt seba sebaga gaii gela gelas s obje objek k untu untuk k preparat 8. Antikoagu Antikoagulan lan (heparin (heparin atau EDTA) EDTA) 9. Perl erlengkapan
untuk
meng engatasi
renjatan
neurogenis
dan
anavilaksis (adrenalin, (adrenalin, atropin, sulfat, dan cauran set infus) ♣
TEMPAT ASPIRASI
Tempat Tempat yang biasa digunakan digunakan aspirasi aspirasi untuk pungsi sumsum sumsum tulang adalah sebagai berikut 1. Spina Spina illiaka illiaka poster posterior ior superi superior or (SIPS) (SIPS) 2. Kris Krista ta illi illiaka aka
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6. Lakuka Lakukan n tinda tindakan kan aseptik aseptik dan antisept antiseptik ik daerah daerah tindaka tindakan n serta serta prosedurterjaga prosedurterjaga aseptik 7. Tentuk Tentukan an titi titik k tindak tindakan an 8. Lakukan Lakukan anastesi anastesi lokal tegak tegak lurus permukaan permukaan,, mulai dari subkutis subkutis sampai periosteal 9. Lakukan Lakukan penetrasi penetrasi jarum jarum aspirasi aspirasi tegak tegak lurus dengan dengan di putar dari kiri ke kanan becara lembut menembus kulit hingga membentur tula tulang ng/p /per erio iost steu eum, m,
kemu kemudi dian an
perh perhat atik ikan an
ting tinggi giny nya a
jaru jarum m
selanjutnya cabut mandrein dan pasang spuit 20 cc yang sudah dibil dibilas as antiko antikoagu agulan lan kemudi kemudian an lakuk lakukan an aspir aspirasi asi perlah perlahan an tapi tapi mantap, cabut souit, biarkan saja jarumnya 10 .
Teteskan
diat diatas as
kaca kaca
aspirat
obje objek, k,
secukupnya
kemu kemudi dian an
akan akan
kegelas terl terlih ihat at
objek,
diratakan
part partik ikel el-p -per erti tike kell
sumsum tulang 11 .
Sisanya masukkan kedalam botol
12 .
Setelah selesai, jaru aspirasi di cabut pelan-pelan tetapi
mantap dengan cara diputar seperti ketika memasukkan tadi 13 .
Pada daerah perlukaan dilakukan penutupanluka dengan
kasa yang telah diberikan antiseptik.
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Meng Mengum umpu pulk lkan an dara darah, h, mema memasu suka kan n obat obat,, memu memula laii infu infus s IV, IV, atau atau menginjeksikan bahan kontras untuk pemeriksaan sinar X dari bagian atau sistem tubuh atau menginjeksikan menginjeksikan substansi untuk uji nuklir. PERSIAPAN
♣
Bahan dan Alat 1. Alkohol Alkohol swab atau antisepti antiseptik k 2. Jarum Jarum tangan tangan steril steril sekali sekali pakai 3. Bantal Bantal kecil kecil atau lip lipatan atan handuk handuk 4. Bantal Bantalan an kas steri sterill 5. Torn Torniq ique uett kare karett 6. Plest ester 7. Tabung Tabung darah darah yang ukurannya ukurannya sesuai sesuai 8. Label Label Ident Identifi ifikas kasii lengka lengkap p 9. Permintaa Permintaan n labor laboratori atorium um lengkap lengkap 10 .
Kantong plastik untuk mengirimkan spesi esimen
11 .
jarum, adapun jarum yang biasanya digunakan adalah
sebagai berikut o
Metode spuit
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1. Bant Bantu u klie klien n pada pada posi posisi si terl terlen enta tang ng atau atau sem semi fowl fowler er deng dengan an lengan lurus 2. Tempatkan Tempatkan handuk handuk kecil kecil dibaw dibawah ah lengan lengan atas atas 3. Buka kemas kemasan an steril steril menggun menggunakan akan teknik teknik steril steril 4. Pil Pilih ih sisi sisi distal distal pada pada vena yang yang akan akan digunakan digunakan 5. Bila
memun emung gkink kinkan an,,
tem tempatka atkan n
leng engan
kli klien
pad pada
posi osisi
dependen 6. Pasang Pasang torniquet torniquet 5-15 cm diatas diatas tempat tempat pungsi pungsi vena. Lingkar Lingkarkan kan torniquet dan kencangkan pada lengan klien, ikatkan satu sama lain, jangan menggunakan ikatan mati. 7. Kenaka Kenakan n saru sarung ng tang tangan an 8. Palpasi Palpasi nadi distal distal dibawah dibawah torniquet, torniquet, bila bila tidak dapat memalpa memalpasi, si, lepaskan tornikuet dan berikan tekanan yang lebih ringan 9. Pil Pilih ih vena vena yang terdilata terdilatasi si dengan dengan baik baik 10.. 10
Bersi ersih hkan kan si sisi punsi unsi vena ena po povido vidone ne iodin din kem kemu udian dian alko alkoho holl
11.. 11
Gerak erakan an dal dalam ger gerakan akan meli elingka ngkarr dar darii tem temp pat tusu tusuka kan n ki kira-
kira 5 cm 12 .
Lepaskan penutup jarum dari spuit atau vacutainer dan
informasikan informasikan klien bahwa ia akan merasakan sakit
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tekanan. Gunakan tangan yang lain untuk menarik jarum dengan menari ke belakang dari sis pungsi vena 21 .
Berika tekanan padatempat injeksi
22 .
Untuk darah yang di dapatkan melalui spuit, pindahkan
spesimen pada tabung, masukan jarum melalui penghenti tabung darah dan biarkan vacum mengisi tabung. Jangan di paksakan 23 .
Untuk
tabung
darah
mengandung
tambahan,
rotasi
kebelakang dan ke depan delapan sampai sepuluh kali dengan perlahan 24.. 24
perha erhati tik kan sisi pung pungsi si untu ntuk per perd darah arahan an dan dan ber beriikan kan pl pleste esterr
(bandaid) 25 .
Tempelkan lab label ide identifikasi asi len lengkap pad pada a setiap tab tabung,
lekatkan daftar permintaan, dan kirim ke laboratorium KOMPLIKASI
♣
Kompl Komplika ikasi si yang yang serin sering g terjad terjadii pada pada pungsi pungsi vena vena adalah adalah terjad terjadiny inya a infeksi.
2.1.4 FLEBOTOM FLEBOTOMII Flebotomi merupakan suatu tindakan menurunkan volume darah
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1. Tensimete Tensimeterr dan stetoskop stetoskop untuk memantau memantau status status hemodinam hemodinamik ik sebelum, selama, dan sesudah tindakan serta untuk membendung aliran vena pada potongan vena 2. Tempat Tempat tidur tidur untuk untuk berbarin berbaring g klien klien 3. Set don donor 4. Boto Botoll (pla (plabo boof of)) atau atau kant kanton ong g pena penamp mpun ung g dara darah h deng dengan an skal skala a volume 5. Set infus infus atau kateter kateter vena vena dan cairan cairan plasma plasma atau atau dekstran dekstran 6. Perangkat Perangkat standar standar antisepti antiseptik k antar lain: pengukur pengukur (gauge) (gauge) steril, steril, povidone iodine, alkohol, dan plaster. ♣
PROSEDUR TINDAKAN
Adapun langkah-langkah dalam melakukan indikasi ini adalah sebagai berikut
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hipervent hiperventilas ilasi, i, diuretik diuretik osmotic osmotic dan steroid steroid (bila perdaraha perdarahan n tumoral) tumoral) digunakan digunakan untuk untuk mengurang mengurangii hipertensi hipertensi intrakran intrakranial ial yang disebabkan disebabkan oleh oleh efek efek mass massa a
perd perdar arah ahan an..
Suda Sudah h
perdar perdaraha ahan n yang yang luas luas mening meninggik gikan an koma,
terutama
yang
bila
dibu dibukt ktik ikan an bahw bahwa a
evak evakua uasi si
surviv survival al pada pada pasien pasien
dilakukan
segera
setelah
dengan dengan onset
perdarahan. Adanya adan adanya ya seba sebaga gaii
hematoma dalam
kela kelain inan an
neur neurol olog ogis is
tind tindak akan an
jaringan
meme memerl rluk ukan an
terp terpil ilih ih..
otak
bersamaan dengan
evak evakua uasi si
Bera Beratn tnya ya
beda bedah h
perda perdara raha han n
sege segera ra inis inisia iall
menggolongkan menggolongkan pasien kedalam tiga kelompok: 1 Perdaraha Perdarahan n progresi progresiff fatal. fatal. Kebanya Kebanyakan kan pasien pasien berad berada a pada keadaan keadaan
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Bila tanpa disertai efek massa jelas, tidak terbukti bahwa operasi terhad terhadap ap PIS kecil kecil,, teruta terutama ma bil bila a terlet terletak ak superf superfis isial ial pada pada su subst bstans ansii putih subkortikal, akan memperbaiki memperbaiki outcome. Dala Dalam m
memp memper erti timb mban angk gkan an
tind tindak akan an
oper operas asii ters tersan angk gka a
PIS PIS
hipertensif, angiogram angiogram penting bila dicurigai ada penyebab potensial lain seperti aneurisma, AVM atau tumor. Sayangnya kemungkinan amiloid tida tidak k begi begitu tu dapa dapatt dipr dipred edik iksi si dan dan bila bila dite ditem mukan ukan mung mungki kin n agak agak menimbulkan kesulitan saat operasi dalam hal mengatasi perdarahan. Sangat Sangat pentin penting g menca mencari ri kelain kelainan an perdar perdaraha ahan n sebelu sebelum m opera operasi si dan mengoreksinya mengoreksinya bila mungkin. Perdarahan
primer fossa
posterior
mempunyai keistimewaan
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Saat pasien datang atau berkonsultasi, evaluasi dan pengelolaan awal harus harus dilakuk dilakukan an bersama bersama tanpa penundaan penundaan yang tida tidak k perlu. perlu. Pemeriksaan neurologis inisial dapat dilakukan dalam 10 menit, harus menyelur menyeluruh. uh.
Informas Informasii ini untuk memastikan memastikan prognosis, prognosis, juga untuk
membuat rencanatindakan rencanatindakan selanjutnya. selanjutnya. Pemeriksaan neurologis serial serial harus dilakukan. Tinda Tindakan kan standa standarr adala adalah h untuk untuk memper mempertah tahank ankan an jalan jalan nafas, nafas, pern pernaf afas asan an,,
dan dan
sir sirkula kulasi si..
Hipo Hi poks ksia ia haru harus s
diti ditind ndak ak
sege segera ra untu untuk k
mencegah cedera serebral sekunder akibat iskemia. Pengamatan ketat dan pengat pengatur uran an tekana tekanan n darah darah pentin penting g baik baik pada pada pasien pasien hipert hipertens ensif if maupun nonhipertensif. Jalur arterial dipasang untuk pemantauan yang sinambung atas tekanan darah. Setelah PIS, kebanyakan kebanyakan pasien adalah adalah
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Fole Foley y terp terpas asan ang, g, dibe diberi rikan kan mann mannit itol ol 1.5 1.5 g/kg g/kg IV. IV. Tind Tindak akan an ini ini juga juga dilakukan pada pasien dengan perburukan neurologis progresif seperti perburukan hemiparesis, anisokoria progresif, atau penurunan tingkat kesadaran. Dilakukan elektrokardiografi, elektrokardiografi, dan denyut nadi dipantau. Dara Darah h diam diambi bill saat saat jalu jalurr intr intrav aven ena a dipa dipasa sang ng.. Hitu Hitung ng lengkap, lengkap,
hitung hitung
platelet, platelet,
dara darah h
elektroli elektrolit, t, nitroge nitrogen n urea darah, darah, kreatini kreatinin n
serum, serum, waktu waktu protromb protrombin, in, waktu
trombopl tromboplastin astin
parsial, parsial,
dan
tes
fungsi hati dinilai. Foto polos dilakukan bila perlu. Setelah penilaian secara cepat dan stabilisasi stabilisasi pasien, dilakukan CT scan kepala tanpa kontras. Sekali diagnosis PIS dib dibawa awa
untu untuk k
mend endapat apatka kan n
pemer emeriiksaa ksaan n
ditegakkan, pasien radi adiolo ologis gis
lain ain
yang yang
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dikor dikoreks eksi. i. Pasien Pasien dengan dengan kelain kelainan an perdar perdaraha ahan n lain lain dikor dikoreks eksii sesuai sesuai dengan penyakitnya. •
Mengurangi Efek Massa Pengurangan efek massa dapat dilakukan secara medikal maupun
bedah. Pasien dengan peninggian TIK dan/atau dengan area yang
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Pasien Pasien sadar sadar dipant dipantau au dengan dengan pemeri pemeriksa ksaan an neurol neurologi ogis s serial serial,, pema pemant ntau auan an TIK TIK jara jarang ng dipe diperl rluk ukan an.. Pada Pada pasi pasien en koma koma yang yang tida tidak k sekarat sekarat (moribu (moribund), nd), TIK dipantau dipantau secara secara rutin. rutin. Disukai Disukai ventrikul ventrikulosto ostomi mi kare karena na memu memung ngki kink nkan an meng mengal alir irka kan n CSS, CSS, kare karena nany nya a lebi lebih h muda mudah h mengontr mengontrol ol TIK. Perdaraha Perdarahan n intra-vent intra-ventriku rikuler ler menjadi menjadi esensial esensial karena karena sering sering terjad terjadii hidro hidrosef sefalu alus s akibat akibat hilan hilangny gnya a jalur jalur keluar keluar CSS. CSS. Lebih Lebih disukai pengaliran pengaliran CSS dengan ventrikulostomi ventrikulostomi dibanding dibanding hiperventilasi
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hipoks hipoksia ia
dan asidos asidosis is serin sering g tampak tampak selama selama
aktifi aktifitas tas
kejang kejang,,
potensial untuk menambah cedera otak sekunder. Pengelolaan metabolik yang baik diperlukan pada pasien dengan PIS. PIS. Status Status cairan cairan,, elektr elektrol olit it serum serum,, dan fungsi fungsi renal renal harus harus ditak ditaksir sir berul berulang ang,, teruta terutama ma pada pada pasien pasien dengan dengan restr restriks iksii cairan cairan,, mendap mendapat at mannitol mannitol atau diuretika diuretika
lain, lain,
atau
tidak
makan. makan. Nutrisi Nutrisi memadai memadai
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Evak Evakua uasi si
ster stereo eota takt ktik ik
atau atau
pemb pembed edah ahan an
seca secara ra
neur neuroe oend ndos osko kopi pi
dilakukan dilakukan pada perdarahan perdarahan intraparenkh intraparenkhimal imal PIS yang terletak terletak dalam dan sulit dijangkau. •
Etiologi Perdarahan Tindakan bedah pada PIS hipertensif hipertensif biasanya dilakukan dilakukan bila lesi
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Waktu aktu
oper operas asii
atas atas
aneu aneuri rism sma a
sere serebr bral al
yang yang
rupt ruptur ur
tida tidak k
ditentukan oleh PIS yang terjadi kecuali pasien memburuk karena efek massa. Bila diperlukan evakuasi hematoma, harus dilakukan tindakan atas aneurismanya pada saat operasi yang sama. PIS sponta spontan n pada pada tumor tumor otak otak mengh mengharu aruska skan n eksplo eksploras rasii bedah bedah serta biopsi rongga hematomanya. Tidak perlu dilakukan secara gawat
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tengah atau yang berkaitan dengan tanda-tanda tanda-tanda kompresi batang otak
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pasi pasien en yang yang stup stupor or atau atau
koma koma prab prabed edah ah
Pent Pentin ing g diin diinga gatt bahw bahwa a
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etiologi etiologinya nya
tak
diketahui diketahui.. Evakuasi endosko endoskopik pik diindika diindikasika sikan n pada
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1. Prosedur Prosedur tindakan tindakan khusus khusus pada ganggu gangguan an hematologi hematologi dapat dapat
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