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PENGERTIAN
Colostomy
adalah suatu tindakan pembedahan membuka dinding abdomen yang bertujuan untuk
mengeluarkan feses.
TUJUAN PERAWATAN COLOSTOMY
1. Mengevaluasi kondisi stoma.
2. Melindungi kulit dari drainase produk kolon.
3. Menjaga kebersihan stoma.
4. Mengganti balutan luka dan colostomy bag.
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NO
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TINDAKAN
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BOBOT
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NILAI
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BOBOT
X
NILAI
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KETERANGAN
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I
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PENGKAJIAN
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2
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1. Mengkaji kembali program/instruksi medik.
2. Mengkaji kondisi kantong colostomy.
3. Mengkaji adanya keluhan ketidaknyamanan/nyeri
disekitar stoma.
4. Mengkaji post operasi hari keberapa.
5. Mengkaji peristaltik usus.
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II
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INTERVENSI
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3
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A. Persiapan
Alat :
1. Kantong colostomy dan penjepitnya.
2. Kapas basah (NaCl 0,9% atau air hangat).
3. Tissue.
4. Handscoen bersih dan steril.
5. Nierbeken / bengkok.
6. Kantong tempat balutan kotor.
7. Pot.
8. Gunting.
9. Handuk dan perlak/pengalas.
10.
Betadine
(kalau perlu untuk lecet dikulit).
11.
Set
ganti balut.
B. Persiapan
Klien :
1. Menjelaskan prosedur dan tujuannya.
2. Memberikan privacy untuk klien.
3. Mengatur posisi tidur klien (semifowler kalau
perlu).
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III
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IMPLEMENTASI
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3
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1. Mencuci tangan.
2. Memakai handscoen.
3. Meletakkan handuk disisi klien.
4. Mendekatkan neirbeken/bengkok.
5. Melepaskan colostomy bag yang sudah kotor dan
meletakkannya di piala ginjal.
6. Mengganti handscoen dengan yang bersih / steril.
7. Membersihkan stoma dan kulit sekitarnya dengan kapas
basah/NaCl.
8. Observasi kondisi kulit, stoma dan jahitan.
9. Mengeringkan kulit disekitar stoma.
10. Memasang kantong colostomy yang baru.
11. Merapikan klien dan alat-alat.
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IV
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EVALUASI
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1
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1.
Mengobservasi
respon klien selama dan sesudah prosedur perawatan colostomy.
2.
Mengevaluasi
integritas kulit sekitar stoma, stoma dan jahitan
3.
Mengevaluasi
karakteristik cairan / feses yang keluar dari stoma (jumlah, konsistensi, dan
warnanya).
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V
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DOKUMENTASI
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1
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1.
Mencatat
respon klien selama pelaksanaan prosedur.
2.
Mencat
waktu tindakan pemasangan dan pengosongan colostomy bag.
4.
Mencatat
karakteristik cairan / feses yang keluar dari stoma (jumlah, konsistensi, dan
warnanya).
5.
Mencat
kondisi kulit sekitar stoma, stoma dan jahitan
3.
Mencatat
partisipasi dan toleransi klien terhadap pemasangan colostomy bag.
4.
Mencatat
penyuluhan keperawtan yang sudah diberikan (bila ada).
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VI
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SIKAP
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1.
Sistematis.
2.
Hati-hati.
3.
Berkomunikasi.
4.
Mandiri.
5.
Teliti.
6.
Tanggap terhadap respon
klien.
7.
Rapih.
8.
Menjaga privacy.
9.
Sopan.
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TOTAL
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10
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Minggu, 20 November 2011
(S.O.P) PERAWATAN KLIEN DENGAN COLOSTOMY
Langganan:
Posting Komentar (Atom)
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