ANEMIA IN INDIVIDUAL

A. Basic Concept of Disease 1. Understanding Anemia Anemia is a reduction in the quantity or quality of red blood cells in circulation. Anemia can be caused by impaired formation of red blood cells, increased loss of red blood cells through chronic or sudden bleeding, or lysis (destruction) of red blood cells redundant. (Corwin, 2001: 119) Anaemia is a condition due to decreased hemoglobin production, increased destruction of blood cells meah and / or due to blood loss. (Potter & Perry, 2006: 1559) Anemia is a term that indicates a low red blood cell count and hemoglobin and hematocrit below normal. (Brunner & Suddarth, 2002: 935) From the above understanding of the anemia, it can be concluded that anemia is a decrease in quality or quantity of red blood cells in the circulation due to decreased hemoglobin production, increased destruction of red blood cells and / or loss of red blood cells. 2. Anatomy of Blood Red Blood Cell Physiology consists of shaped elements and the plasma in the number of equivalent. The elements are shaped red blood cells (erythrocytes), white blood cells (leukocytes), and blood-chip (thrombocyte). Plasma consists of water 90%, and 10% of electrolytes, dissolved gases, various waste products of metabolism and nutrients such as sugars, amino acids, fat, cholesterol, and vitamins. Protein in the blood such as albumin, imunoglobin, and component levels of coagulation and is co-author of the plasma component. Other proteins in the plasma serves to transport a variety of hormones and fat soluble which is actually difficult. Examples of materials transported bound to plasma proteins is low and high density of thyroid hormone, iron, phospholipids, and cholesterol. a. Formation Blood Cells Red blood cells, white blood cells, and thrombocyte formed in the liver and spleen in the fetus, and bone disumsum after birth. The process of formation of blood cells called hematepoiesis. Originated from the bone marrow hematopoiesis of cells would pluripotensial (meaning having a lot of potential / likely). Cells would be the source of all blood cells. These cells have reproductive cells through DNA replication and mitosis, and differentiation of cells when they begin to split and develop into red blood cells, white blood cells, or thrombocyte. The process of formation of red blood cells can be seen in chart 2.1 below. Chart 5.1 simple diagram of blood cell differentiation in bone marrow. Whole blood cells derived from the cell would b. The control of cell growth would be Tues, stimulated to form blood cells receive the mark by in utero and after birth. These signs include the release of local product molecules, which is an indication of the state density in the hematopoietic tissue. Sign also includes the circulation of hormones, (hematopoietic growth factors) that stimulate plorifelari many or all cells. Hemaopoietik growth factor specific for cells which they called factor stimulation penstimulasi colony (colony-stimulating factor). c. Red Blood Cells Red blood cells (erythrocytes) did not have a cell nucleus, mitochondria, or ribosomes. These cells can not perform mitosis, cell oxidative phosphorylation, or formation of proteins. Red blood cells contain the protein hemoglobin carries most of the oxygen yag taken in the lungs to cells throughout the body. Hemoglobin occupying most of the intracellular space of erythrocytes. Mature blood cells are removed from the bone marrow and lived about 120 days to then experience the disintegration and death. Red blood cells that died was replaced by new cells produced by bone marrow. Red blood cell structure is shown in the figure below: Figure 2.1 Structure of Red Blood Cells Source: tinkling bells Hati.htm (accessed on March 27, 2008) d. Nature-Nature of Red Blood Cells Red blood cells are usually described by size and amount of hemoglobin contained in the cells: 1) Normositik: Cells of normal size 2) Normokromik: Tue with a normal amount of hemoglobin 3) microcytic: Cells that are too small in size 4 ) Makrositik: Cells that are too large in size 5) Hipokromik: Cells that amount is too little hemoglobin 6) Hiperkromik: Cells that amount of hemoglobin is too much Under normal circumstances, shape of blood cells can be fickle. This property allows these cells to enter or pass without causing damage and capillary microcirculation. If the red blood cells is difficult to change shape (rigid), then those cells can not survive during its circulation in the circulation. e. Red Blood Cell Antigen red blood cells have a variety of specific antigens located on cell membranes and not found in other cells. Antigen-antigen is named A and B and Rh. ABO antigens A person has two alleles (genes) that encode each of antigens A or B, or do not have both, which is named O. One allele is received from each parent. Antigens A and B are codominant. People who have antigens A and B (AB) will have blood (groups) AB. Those who have two antigen A (AA) or one A and one O (AO), will have the blood of A. Those who have two antigen B (BB), or one B and one O (BO), will have the blood B. People who do not have a second antigen (OO) will have the blood of O. People who have blood type AB blood will receive an A, B or O However, people who do not have the antigens A and B will form an immune response when exposed to the antigen-antigen during blood transfusions. Rh antigens are the other main group antigens on red blood cells as well as the genes inherited from each parent. Major Rh antigen called Rh factor. People who have Rh antigens are considered Rh positive (Rh +). People do not have Rh antigens are considered Rh negative (Rh-). Rh positive gene is dominant. Thus, one should have two negative factors to be Rh negative. Rh positive person who will receive Rh negative blood, but those who do not have Rh antigens to form immune response if exposed to Rh positive blood. f. Universal Blood Donor and recipient blood recipients are those who have the universal blood-AB positive blood because their immune system will regard A or B antigen positive and Rh antigens as part of themselves (not foreign objects). Thus, they can receive all the profiles of ABO and Rh. Universal blood donors are those who have O negative blood Despite their negative immune system will attack the blood that contain antigens A or B and Rh factor, they can be given blood transfusions to all the recipients. g. Hemoglobin Hemoglobin consists of iron containing materials called hem (heme) and globulin proteins. There are about 300 molecules hemogobin in each red blood cell. Each hemoglobin molecule has a binding site for oxygen. Called hemoglobin that binds oxygen-globin oksihemo. Hemoglobin in the blood can bind oxygen partial or total in the fourth place. Hemoglobin that binds oxygen fully saturated / total, while that of saturated hemoglobin deoksigenasi will experience a partial saturation of less than 100%. Systemic arterial blood from the lungs is saturated with oxygen. Hemoglobin to release oxygen to the cells so that the saturation of hemoglobin in the blood of the pen is about 60%. Hemoglobin final task is to absorb carbon dioxide and hydrogen ions and bringing them into the lungs where these substances are released from hemoglobin. There are at least 100 types of abnormal hemoglobin molecules which are known in humans, which is formed from a variety of mutations. Most part types are less capable of transporting oxygen than normal hemoglobin. h. Split Red Blood Cell When red blood cells begin berdisintegrasi at the end of its life, these cells release hemoglobin into the circulation. Hemoglobin described in the liver and the spleen. Globulin molecules converted into amino acids which are used again by the body. Iron is stored in the liver and the spleen to be reused. Time changed to another molecule bilirubin, which then dieksresikan through feces as bile or urine. 3. A. Etiology Aplastic anemia aplastic anemia is anemia normokromik normositik caused by bone marrow dysfunction such that the blood cells that die are not replaced. Caused aplastic anemia by many things including bone marrow cancer, bone marrow destruction by autoimmune processes, vitamin deficiency, various drugs and radiation or chemotherapy. (Corwin, 2001: 122-123) b. Hemolytic anemia hemolytic anemia is a decrease in the number of red blood cells caused by excessive destruction of red blood cells. Hemolytic anemia may occur due to genetic defects in red blood cells, autoimmune disease or may be obtained due to pejanan certain drugs or toxins. (Corwin, 2001: 124) c. Sickle cell anemia Sickle cell anemia is a recessive disorder caused by inheritance otosom two copies defiktif hemoglobin genes, one from each parent. The defective hemoglobin, called hemoglobin S (HbS), become stiff and shaped like a crescent due to low-oxygen exposure. Stimuli that often lead to the formation of sickle cells is physical stress, fever or trauma. d. Anemia Anemia, Post-post-bleeding Bleeding is normositik normokromik anemia caused by sudden blood loss in healthy people. Bleeding can be unclear or vague. (Corwin, 2001: 128) e. Pernicious anemia pernicious anemia is anemia due makrositik normokromik vitamin B12 deficiency. Vitamin B12 is absorbed by the intrinsic factor produced by gastric hormones. Most of the causes of pernicious anemia is caused by deficiency of intrinsic factor, but can also occur in food vitamin B12 deficiency. Intrinsic factor deficiency can occur in congenital or due to atrophy or destruction of gastric mucosa due to chronic gastric inflammation or autoimmune disease. Appointment of part or all of the stomach in surgery will also cause deficiency of intrinsic factor. (Corwin, 2001: 129) f. Folate Deficiency Anemia of folate deficiency anemia is anemia due to deficiency normokromik makrositik-vitamin folate. Deficiency occurs relatively frequently in young women and all people suffering from malnutrition or alcohol abuse. (Corwin, 2001: 130) g. Iron Deficiency Anemia Iron deficiency anemia is a microcytic anemia hipokromik caused by iron deficiency in nutrition or blood loss is slow and chronic. (Corwin, 2001: 131) h. Sideroblastik Anemia Anemia is sideroblastik-hipokromik microcytic anemia characterized by the presence of red blood cells are immature (sideroblas) in the circulation and bone marrow. Sideroblastik Anemia can occur due to primary genetic effect on chromosome X that is rarely found (mainly found in the male) or can arise spontaneously, especially in older people. Secondary causes of anemia sideroblastik are certain drugs, such as some chemotherapy drugs and the ingestion of lead. (Corwin, 2001: 131-132) 4. A. Pathophysiology Anemia due to decrease in Red Blood Cell Anemia caused by disturbances in the quality of the formation of red blood cells arise if the red blood cell size is too small (microcytic) or too big (makrositik). Anemia associated with the quality of red blood cells also occur if an interruption occurs the formation of hemoglobin. This will cause excessive high concentration of hemoglobin (hiperkromik) or low excess (hipokronik). b. Anemia due to lysis or anemia caused by sudden haemorrhage or bleeding lysis associated with sudden decrease in the total number of red blood cells in the circulation. Red blood cells normally live about 120 days. Destruction or loss of red blood cells that occurs before 100 days is abnormal 5. Clinical manifestation of anemia characterized by hemoglobin levels below normal. Clinical manifestations of this condition include fatigue, decreased activity tolerance, increased shortness of breath, looking pale and increased heart rate. (Potter & Perry, 2006: 1559) a. Systemic signs of anemia that is classic: 1) Increased heart rate because the body tries to give more oxygen to the network 2) Increased respiration rate as the body attempts to provide more oxygen to the blood 3) Headache caused by decreased blood flow to the brain 4) Pain tired due to the increased oxygenation of the various organs including the heart and skeletal muscles 5) Skin pale due to reduced oxygenation six) Nausea from a decrease in gastrointestinal blood flow and central nervous system 7) Impairment of quality hair and skin b. If the thrombocyte and white blood cells are also affected, the symptoms increased with: 1) Bleeding and bruising easily arise 2) recurrent infections 3) The wound skin and mucous membranes are difficult to recover c. In sickle cell anemia, the symptoms increased with: 1) severe pain caused by vascular obstruction at the second disease attacks), recurrent bacterial infections 3) Splenomegali because spleen cells clean up the dead d. Ataxia (motor coordination disorder suggest dysfunction and reduced sensory and central nervous system myelin degeneration and mental activity can be affected for the client with pernicious anemia. E. Landfill iron causes hepatomegaly and splenomegali in clients with iron deficiency anemia. 6. Impact on the Body Structure and Function Other Increased heart rate because the body tries to give more oxygen to the network. It can occur with heart failure due to severe anemia. Increased respiration rate as the body attempts to provide more oxygen to the blood. Nausea caused by decreased blood flow of the gastrointestinal tract and central nervous system, splenomegali because cleaning spleen cells die, causing iron accumulation hepatomegaly. Clients are at risk of anemia occurs decubitus. Decrease in hemoglobin level reduced blood oxygen-carrying capacity and reduce the amount of oxygen available to the network. Anemia also interfere with cell metabolism and interfere with wound healing. (Potter & Perry , 2006: 1260), and decreased quality of hair and skin, bleeding and bruising easily arise. feeling tired due to the increased oxygenation of the various organs including the heart and skeletal muscle. ataxia (motor coordination problems and reduced sensory dysfunction suggest and degeneration of the central nervous system myelin and activities can be affected mentally, dizziness caused by reduced blood flow to the brain, severe pain caused by vascular obstruction in the attacks of diseases. 7. Management of Medical Investigations of anemia include: a. The bone marrow biopsy in aplastic anemia b. Examination decreased hematocrit, hemoglobin and calculate c. Examination of red blood cells to identify the status of prenatal fetal homozygous at (sickle cell anemia) d. blood analysis will show cells makrositik-normokromik (pernicious anemia and folate deficiency). e. Analysis of blood cells will show microcytic-hipokromik and a decrease in serum iron (iron deficiency anemia) f. Fecal examination to look for faint blood may be positive, suggesting bleeding or gastrointestinal carcinoma (iron deficiency anemia) g. The bone marrow examination showed accumulation of iron, sideroblas and phagocytic macrophages (sideroblastik anemia). The treatment will depend on the type of anemia experienced. Here are some codes of conduct on anemia: a. Treat the underlying disease, if known, or avoid causing ingredients. b. transfusions to alleviate the symptoms. c. d. Immunosupresi bone marrow transplantation when caused by autoimmune disease . e. medicine to stimulate bone marrow function may be effective. profilaktif f. Antibiotics can be given to prevent infection. g. Supplementation of folic acid can stimulate the formation of red blood cells h. Good hydration can reduce the occlusion. i. Avoid situations or activities of oxygen deficiency requiring oxygen. j. injection of vitamin B12. k. The oral folate. l. The iron-rich diet containing meat and green vegetables such as spinach. m. oral iron supplements. n. Treat the cause of abnormal bleeding if any. o. The cause of the disease when associated with the drug should be removed. p. piridoksin Drugs may cure disease. Doenges B. Nursing Process (1999: 6) states that nursing care is an important factor in patient survival and the maintenance aspect, rehabilitative and preventive health care. Implementation nursing care to clients with anemia using the nursing process which consists of four stages, as proposed by Yura And Walls (1967), namely the assessment, planning, execution or implementation and evaluation, in which nursing diagnoses included in the assessment stage (Gaffar, 1999: 54) . 1. The assessment In the assessment phase of efforts to obtain data and or information will be grouped and analyzed so that it can be formulated nursing diagnoses that will be overcome at the planning stage. The process of assessment through several stages, including: a. Data Collection 1) The identity of a ) Identity Client Data obtained includes name, age, gender, ethnicity / nation, religion, address, medical diagnosis of anemia, No.RM / CM, entry date and the date of the Hospital was doing the assessment. w) The identity of the responsible Data obtained by the responsible person's name, age, education, occupation, address and relationship with the client. 2) Medical history a) The main complaint with anemia Clients generally will experience fatigue and shortness of breath. b) Medical history now includes descriptions of the main complaints are kronolgis. Description answer questions relating to where (location), what (quality, factors that aggravate or relieve the symptoms), when (attack, duration, frequency), and how much (intensity, severity), was also asked about the related manifestations . (Engel, 1999: 12). Fatigue and shortness of anemia is felt when the activity and decreases with rest or administration of oxygen. c) a past medical history should be studied mainly to know the client's experience in undergoing treatment and care, history of drug use causes anemia, underwent experience kemotherapi, vitamin habits, alcohol abuse, history of trauma or exposure to radiation serta history of allergy who owned clients. d) Medical history family medical history should be studied anemia in her family and the family experience in dealing with family members who suffered from anemia. 3) Patterns Patterns habits Habits include such things as follows: a) Pattern Assessment Nutrition nutrition is an important first step in nursing care and preventive health services. Assessment of nutritional help in identifying eating habits, misunderstandings and symptoms that can give an indication of nutritional problems. (Engel, 1999: 38). Review of nausea and other eating disorders. b) Assess the Pattern Elimination of gastrointestinal bleeding (melena or blood in the stool content) and hematuri if any. c) Rest and Sleep Patterns Determine the side effects of treatment on sleep patterns. Monitor the client's sleep patterns and note the relationship of physical factors (such as sleep apnea, airway obstruction, pain / discomfort and frequent urination) or psychological factors (such as fear or anxiety) that can disrupt sleep patterns. (Wilkinson, 2007: 478) d) Assess the Activity Pattern of the client's ability in performing activities using the endurance level (Gordon in Wilkinson, 2007: 3) as follows: Level 1: Walk in the regular speed on a plane, but the breathing became more shorter than normal when one or more stairs to climb. Level 2: Walking a city block or climb 1500 meter horizontal one or climbing stairs slowly without stopping. Level 3: Walk horizontally no more than 150 meters without stopping and no one is able to climb stairs without stopping. Level 4: dyspnea and fatigue when resting. e) The pattern of the Personal Hygiene Perform ability to conduct compliance assessments of personal hygiene to the following indicators (value 1-5: dependence [not able to participate], require another person or a hearing aid, requiring the assistance of others, independently with the aid of tools, fully independent). (Wilkinson, 2007: 420). 4) Physical Examination a) General Appearance Clients with anemia would appear weak and congested. b) Inspection Persistem a) Assess Cardiovascular System throbbing wall of the thorax, heart frequency count for one minute, percussion heart, examine the state of the conjunctiva, blood pressure, CRT, calculate the JVP pressure, auscultation of heart sounds of rhythm, whether there is any abnormal heart sounds, rank , high-low tone, quality, assess whether there is cyanosis, finger clubber. In the client with anemia found rapid heart rate, conjunctival anemis, and complications of heart failure can occur due to severe anemia. b) Digestive System Check oral cavity, lip mucosa review, assess whether there is any tartar, teeth, observe the shape of the abdomen, observe whether there is any swelling, peristaltic intestinal auscultation, examine whether there is pain with palpation or without palpation, check the belly skin turgor , MC Burney check point area, region epigastric, do the liver and spleen palpation. In the client with anemia found nausea, splenomegali and hepatomegaly. c) Breathing System Review whether there is any nasal secretions, observe form the thorax, auscultation of breath, count the frequency of breathing, respiratory rhythm examine, observe whether or not there is also dyspnea, intercostal retraction, nostril breathing, palpation of chest wall vibration, review of cyanosis. In the client with anemia found increased respiration rate and feeling crowded. d) Assess the situation Integumentary System Hair, color, growth, and dissemination of, easy to fall off or not, review head hygiene, examine the skin moisture, warmth, body temperature. In the client with anemia found in the data slowing wound healing, decreased quality of hair and skin, easy bleeding and bruising occur until decubitus. e) System Review Muskulo skeletal form upper and lower extremities, assessing range of motion (Range of Motion), muscle strength test, there tidaknnya examine fracture. In the client with anemia was found exhausted and feeling weak. f) Assess Persyarafan System client awareness, assess the quantitative assessment of consciousness, cranial nerve examination test. In the client with anemia found ataxia and distractions of mental activity, dizziness and severe pain. g) Assess the Endocrine System with palpation of the lymph glands, thyroid gland check by inspection, review forms, symmetry, thyroid auscultation. In the client with anemia did not crash the endocrine system h) System of a supra pubic area urinal Palpation, percussion kidney at Angel costovertebrata area (CVA), presence or absence of bladder distension. In the client with anemia not find abnormalities in urination system. 5) Psychological Data a) Emotional Status Review the status of client emotions. Emotion client with anemia usually unstable, the client is worried because they do not know about his illness. b) Self-concept (1) Body image perception Ask clients about their bodies. Parts of the body's likes and dislikes. (2) Assess the status of self-identity and position of the client prior to treatment, client satisfaction of the status and position (schools, workplaces, groups). (3) Role Ask a task or role that carries the family, and group or community. Assess client's ability in carrying out the task or role. (4) Ask Yourself Ideal client expectations to the body, position, status, tasks or role, assess the ability of clients to the environment and expectations of clients against the disease. (5) Self-Esteem Ask client relationships with others, ask the assessment or appreciation of other people to himself and his life. c) Long Term and Short stressor Kaji about issues facing clients in the last six months, review is also about new problems experienced. d) Mechanism Koping Assess client's ability to solve problems. e) Hope and Understanding Client Review of Current Condition on client expectations and assess current knowledge about the client's current condition. Six), Social and Cultural Data Kaji client communication patterns and interpersonal interactions, review of lifestyle, sociocultural factors, family support systems and economic status. 7) Data should be reviewed Spiritual beliefs of clients, sources of power, and the views of the disease that was suffered. 8) Data Supporting a) The bone marrow biopsy in aplastic anemia b) Examination decreased hematocrit, hemoglobin and red blood cell count c) prenatal examination to identify the status of a fetus homozygous at (sickle cell anemia), d) blood analysis will show selsel makrositik-normokromik ( pernicious anemia and folate deficiency). e) blood analysis will show microcytic cells-hipokromik and decrease serum iron (iron deficiency anemia), f) Inspection of the stool to look for faint blood may be positive, suggesting bleeding or gastrointestinal carcinoma (iron deficiency anemia) g) of bone marrow examination showed iron accumulation, and macrophage phagocytic sideroblas (anemia sideroblastik) b. Analysis of the data analysis process is to connect the data obtained with the concepts, theories, principles of nursing care that are relevant to the client. Data analysis through data validation, data grouping, comparing the data, determines the gaps / data gaps, interpret the existence of inequality / disparity of data and make conclusions about the gaps / problems. (Gaffar, 1999: 60) c. Nursing diagnosis nursing diagnosis is a statement which describes the status or the actual or potential health problems. (Gaffar, 1999: 61). Nursing diagnosis on the client with anemia by Engram (1999: 423-433) are: a. Pain associated with factors: Damage to tissue perfusion secondary to vaso-Occlusive crisis. b. Impaired self-concept associated with factors: the rejection of others secondary to chronic pain. c. Activity intolerance related to factors: Anemia d. High risk of damage to the management of maintenance in the home associated with factors: Lack of knowledge about the condition and plan of action. 2. A. Planning Pain-related factors: Damage to tissue perfusion secondary to vaso-Occlusive crisis. Limitation characteristics: Expressing pain, facial grimacing, moaning, crying, to protect the side of pain, has a lesion on the foot. Results of patients (collaborative): Demonstrating missing from chronic pain evaluation criteria: Denying pain, facial expression relaxed. Rational intervention first. During a sickle cell crisis, monitor: Results of laboratory reports (GDA, JDL, serum electrolytes, chemistry profile) vital signs every four hours and haluaran Enter each eight hours of general status (Appendix F) every eight hours to identify indications of progress or deviations from expected results 2. Maintain head of bed elevated to allow maximum lung expansion 3. Tirah Keep lying to the limitations of activity until pain and dyspnea is reduced to conserve energy 4. when fever exists; give antipyretics and antibiotics prescribed and recommend at least 2-3 liters of fluid intake daily and complex carbohydrate foods (bread, cereal, potatoes, pasta) Antipyretics help adjust the thermostat to lower body temperature. Fever to increase metabolic rate. Complex carbohydrates provide calories needed to meet rising energy basal metabolic rate (BMR). Loss of fluid is increased when rate increases mentabolisme. Fluids also help to wash the collected cells and stop the formation of sickle cells. 5. Give a narcotic analgesic, if necessary, the muscle relaxants, and tranquilizer. Kefektifannya evaluation. To control severe pain. Many doctors find that the tranquilizer and muscle relaxants when used with analgesics provides more effective removal of pain for a longer period. 6. Give oxygen through nasal kanula at 6 L / min. Encourage use of fingers or ear oximetry to monitor oxygen saturation continuously when there is severe dyspnea. Supplemental oxygen to help increase oxygen tension and increase oxygen saturation approached normal limits, 90-100mmHg. 7. Give transfusion packaging facility determined in accordance with protocols and procedures. Monitor trasnfusi reactions (Table 6-2). Follow the facility procedure when a reaction occurs trasnfusi. Most aimed to maintain hemoglobin at approximately 10g/dl. This takrealistis to expect a normal hemoglobin level in patients with cell anemia crescent. HR packaging is given to replace blood cell components without adding volume. 8. consult with your doctor if the urine becomes turbid These findings indicate excessive hemolysis of human resources and the need for evaluation of renal function b. Self-concept disturbance associated with factors: Rejection of others secondary to chronic pain. Limitation characteristic: Reveal experience rejection, reported a low price, despair, or takbermakna, can be reported withdrawing from social activities. Results of patients (collaborative): Demonstrate effective coping with chronic illness. Criteria of evaluation: Revealing the acceptance of self on the scene, revealing the work plan realistic. Interventions Rationale 1. Evaluation of the use of social relationships in the community. Refer patients with sickle cell disease on the foundation of local (if any). These agencies provide information on all aspects of sickle cell disease and its nature. Can also provide information about support groups. 2. Refer patients in vocational counseling when necessary. When the election of a job, considering the strength and physical endurance of individuals. Work requires heavy physical exertion is a career takrealistis for individuals with sickle cell anemia. 3. Encourage families to treat individuals with sickle cell disease, such as other household members, not as people with disabilities. Emphasize the need for patients to avoid distinguish themselves with others. Self-esteem is enhanced when the patient feel valued as individuals with meaning and dignity. c. Intoleransi Aktivitas berhubungan dengan faktor : Anemia Batasan karakteristik : Melaporkan kelelahan menetap, dispnea pada pengerahan tenaga, dapat melaporkan palpitasi; dapat menunjukkan takikardia dan takipnea pada istitahat. Hasil pasien (kolaboratif) : Mendemonstrasikan peningkatan toleransi pada aktivitas. Kriteria evaluasi : Melaporkan berkurangnya kelelahan dan dispnea bila melakukan rutin, frekuensi nadi 60-100 nadi per menit, dan frekuensi pernapasan 12-24 per menit istirahat. Intervensi Rasional 1. Pantau: Hasil JDL dan gas darah arteri (GDA) Tanda vital setiap 4 jam Toleransi pada aktivitas fisik Untuk mengidentifikasi indikasi-indikasi kemajuan atau penyimpangan dari hasil yang diharapkan. 2. Konsul dokter bila pasien mengalami denyut jantung tak teratur, takikardia menetap, rales disertai oleh penurunan haluaran urine dan peningkatan tekanan darah. Abnormalitas jantung dapat terjadi pada anemia berat karena hipoksemia miokard. Sebagai respons kompensasi pada hemoglobin rendah, frekuensi jantung meningkat untuk memenuhi kebutuhan tubuh terhadap oksigen pada adanya saturasi oksigen darah rendah. Suhu tubuh mungkin lebih rendah daripada normal karena vasokonstriksi perifer dan pirau darah ke organ sentral. 3. Bila pasien menunjukkan hipoksia ekstrem, lakukan tindakan yang ditentukan seperti oksigen suplemen, trasnfusi darah, dan tira baring pada posisi semi-Fowler. Bila transfusi darah dilakukan, pantau terhadap reaksi transfusi (Tabel 6-2) per prosedur fasilitas. Implementasikan protokol fasilitas bila terjadi reaksi. Oksigen suplemen meningkatkan jumlah ketersediaan oksigen pada SDM. Tirah baring menurunkan kebutuhan jaringan terhadap oksigen. Transfusi darah lengkap atau SDM kemasan memberikan cara cepat meningkatkan jumlah SDM dan hemoglobin dan nilai hematokrit. Posisi tegak memungkinkan ekspansi paru penuh. 4. Instruksikan pasien untuk melakukan aktivitas sesuai toleransi dan menghindari pengerahan tenaga berlebihan. Berikan bantuan sesuai kebutuha dengan AKS. Bantu pasien dengan memprioritaskan aktivitas dan merencanakan periode istirahat selama sehari. Periksa ferkuensi nadi sebelum dan setelah aktivitas fisik. Aktivitas fisik meningkatkan konsumsi oksigen. Istirahat meningkatkan kebutuhan energi tubuh. Ketahanan fisik ditingkatkan bila pengerahan tenaga fisik diimbangi dengan istirahat. 5. Anjurkan pasien menggunakan anti-emetik sesuai pesanan, dimana dapat meliputi suplemen besi, vitamin B12, dan asam folat. Jelaskan tujuan suplemen yang diresepkan Nutrien ini esensial untuk eritropoeisis dan sintesis hemoglobin. 6. Bila tak mampu menggunakan preparat besi per oral dan impferon yang diresepkan, gunakan langkah yang tepat untuk meminimalkan ketidaknyamanan dari injeksi intramuskular dari obat ini: Ganti jarum setelah menghentikan larutan dari vial. Gunakan metoda injeksi Z-track. Berikan intramuskular dalam (IM) dengan menggunakan otot gluteal. Tambahkan 0,2mL udara pada spuit yang berisi obat-obatan. Imferin sangat mengiritasi pada jaringan subkutan dan dapat menyebabkan pewarnaan permanen. Tindakan ini menjamin bahwa obat-obatan disimpan hanya di dalam otot. 7. Anjurkan pasien untuk meningkatkan masukan diet daging jeroan (khususnya hati) kuning telur, kacang-kacangan, makanan laut sayuran berdaun hijau, roti gandum dan sereal. Makanan ini sumber terbaik dari besi, vitamin B12, dan asam folat. d. Risiko Tinggi Terhadap Kerusakan Penatalaksanaan Pemeliharaan Di Rumah berhubungan dengan faktor : Kurang pengetahuan tentang kondisi dan rencana tindakan Batasan karakteristik : Mengungkapkan kurang pemahaman. meminta informasi, melaporkan riwayat ketidakpatuhan.. Hasil pasien(kolaboratif) : Mendemonstrasikan keinginan memenuhi rencana perawatan. Kriteria evaluasi : Mengungkapkan pemahaman tentang kondisi dan rencana tindakan, solusi terhadap anemia. Intervensi Rasional 1. Hindari penggunaan botol air panas atau bantalan pemanas untuk mengatasi sensitivitas dingin. Berikan instruksi tentang tindakan untuk menghemat panas tubuh untuk menghilangkan sensitivitas dingin : Meningkatkan suhu ruangan Menggunakan selimut ekstra Menggunakan pakaian ekstra Penggunaan sumber pemanas secara langsung pada tubuh dapat mengakibatkan luka bakar. Sensitivitas dingin adalah refleksi dari upaya tubuh untuk mengkompensasi hipoksemia kronis dengan menurunkan laju metabolisme dan pirau darah ke organ vital. Tindakan penghematan panas ini membantu mencegah kehilangan panas tambahan dari tubuh. 2. Berikan informasi tentang kondisi primer yang menyebabkan anemia. Jelaskan bagaimana ini menimbulkan anemia. Artikan anemia dan tanda-tandanya serta gejala-gejalanya. Jelaskan tujuan therapi yang ditentukan. Penyuluhan kesehatan meningkatkan kerja sama pasien dan kepatuhan dengan rencana therapeutik 3. Bila terapi besi dilanjutkan di rumah, berikan instruksi berikut : Obat-obatan menjadikan feses hijau gelap. Bila konstipasi atau diare terjadi, beri tahu dokter. Perubahan pada dosis atau interval dapat mengatasi masalah usus. Gunakan suplemen besi dengan jus sitrus karena vitamin C dan asam sedang meningkatkan absorpsi besi. Penyuluhan kesehatan penting untuk meningkatkan keamanan dalam perawatan mandiri di rumah. Gunakan setelah makan untuk meminimalkan ketidaknyamanan gaster. Bila preparat cair digunakan, larutkan dengan jus sitrus minum dengan sedotan untuk mencegah pewarnaan gigi. Pertahankan perjanjian evaluasi untuk mendapatkan pemeriksaan hemoglobin dan hematokrit. Laporkan tanda-tanda toksisitas besi pada dokter: sakit kepala, rasa besi, kekakuan sendi. 4. Jelaskan bahwa ini dapat memerlukan waktu beberapa minggu sebelum hasil ditunjukkan dari suplemen besi oral. Kekurangan simpanan besi harus diperbaiki sebelum ada bukti dalam pemeriksaan serum, biasanya kira-kira dua bulan. 3. Implementasi Implementasi merupakan perencanaan keperawatan oleh perawat dan klien. Hal-hal yang harus diperhatikan ketika melakukan implementasi adalah intervensi dilaksanakan sesuai rencana setelah dilakukan validasi, penguasaan keterampilan interpensional, intelektual, dan teknikal, intervensi harus dilakukan dengan cermat dan efisien pada situasi yang tepat, keamanan fisik, dan psikologi dilindungi dan dokumentasi keperawatan berupa pencatat dan pelaporan (Gaffar, 1999 : 65). Perawatan pada klien dengan anemia mencakup manajemen nyeri, observasi tanda-tanda vital, pemeriksaan laboratorium darah, observasi tingkat toleransi pada aktivitas fisik, pemberian transfusi darah dan kebutuhan oksigenasi, pemenuhan kebutuhan nutrisi serta pemberian pendidikan kesehatan tentang kondisi, program pengobatan dan kebutuhan perawatan pada klien dengan anemia. Salah satu tindakan fokus pada anemia adalah pemberian transfusi darah. Potter (2000 : 634-641) menyatakan langkah-langkah pemberian transfusi seperti yang terlihat pada tabel berikut ini. Tabel 2.1 Prosedur Pemberian Transfusi Peralatan : a. Selain alat-alat yang digunakan untuk memberikan infus intra vena b. Larutan normal salin 0,9% c. Set infus dengan filter dalam d. Kateter besar (diameter 18-G atau 19-G) e. Produk darah yang benar f. Sarung tangan sekali pakai Langkah-Langkah Rasional a. Cuci tangan b. Kenakan sarung tangan sekali pakai c. Jelaskan prosedur pada klien. Tentukan apakah klien pernah mendapatkan transfusi sebelumnya dan catatan reaksi jika ada. d. Pastikan bahwa klien telah menandatangani format persetujuan. e. Buat jalur intra vena dengan kateter besar (diameter 18-G atau 19-G) f. Gunakan selang infus yang memiliki filter. g. Gantungkan wadah larutan 0,9% NaCl untuk diberikan setelah menginfuskan darah. a. Mengurangi transmisi mikroorganisme. b. Mengurangi transmisi patogen darah. c. Klien yang pernah mendapatkan transfusi darah pada masa lalu dapat merasakan ketakutan yang lebih besar terhadap transfusi. d. Beberapa institusi memerlukan klien untuk menandatangani surat persetujuan sebelum menerima transfusi komponen darah. e. Memungkinkan infus darah lengkap dan mencegah hemolisis. f. Filter mengangkat debris dan bekuan darah kecil. g. Mencegah hemolisis sel-sel darah merah. h. Ikuti protokol institusi dalam mendapatkan produk darah dari bank darah. Minta darah bila anda telah siap menggunakannya. i. Dapatkan data dasar tanda-tanda vital 30 menit sebelum pemberian transfusi darah. Laporkan adanya peningkatan suhu pada dokter. j. Tusuk unit darah, pencet bilik drip dan biarkan filter terisi darah, buka klem pengatur dan biarkan selang infus terisi darah. k. Hubungkan selang transfusi darah ke kateter intra vena dengan mempertahankan kesterilan. Buka klem bagian bawah. l. Tetap bersama klien selama 15 menit sampai 30 menit masa transfusi. Kecepatan aliran awal selama waktu ini harus 2 sampai 5 ml/ menit. m. Pantau tanda-tanda vital klien tiap 5 menit selama 15 menit pertama, tiap 15 menit selama satu jam berikutnya, tiap jam sampai unit darah terinfuskan dan selama satu jam setelah infus selesai. h. Darah lengkap atau kemasan sel-sel darah merah harus tetap dalam lingkungan dingin (1-6 oC). i. Memastikan suhu, nadi, tekanan darah, dan pernapasan pra transfusi klien dan memungkinkan deteksi reaksi transfusi dengan mempertahankan perubahan pada tanda-tanda vital. j. Menyiapkan filter dan selang terisi darah. Membantu mempercepat hubungan dari selang infus yang telah disiapkan ke kateter intra vena. k. Memulai infus produk darah ke dalam vena klien. l. Kebanyakan reaksi transfusi terjadi selama 15 sampai 30 menit transfusi. m. Waspadalah terhadap setiap perubahan tanda-tanda vital yang dapat merupakan tanda awal reaksi transfusi. n. Atur infus sesuai pesanan dokter. Kemasan darah biasanya diberikan 1 sampai 2 jam sementara darah lengkap diberikan selama 2-3 jam. o. Setelah darah diberikan, bersihkan selang infus dengan normal salin 0,9% dan letakkan kantung darah pada kantung plastik untuk dikembalikan ke bank darah. p. Buang semua bahan yang telah digunakan di tempat yang telah disediakan. Lepaskan sarung tangan dan cuci tangan. q. Catat tipe dan komponen darah yang diberikan dan respon klien terhadap therapi darah. Biasanya digunakan catatan transfusi darah. n. Kondisi klien menentukan kecepatan darah yang harus diberikan. Faktor tetesan untuk selang darah adalah 10 tetes/menit. o. Menginfus sisa darah di dalam selang intra vena, normal salin 0,9% mencegah hemolisis sel-sel darah merah. p. Mengurangi transmisi mikroorganisme. q. Mencatat pemberian komponen darah dan reaksi klien. 4. Evaluasi dan Catatan Perkembangan Fase akhir dari proses keperawatan adalah evaluasi terhadap asuhan keperawatan yang diberikan. Hal yang dievaluasi adalah keakuratan, kelengkapan, dan kualitas data, teratasi dan tidaknya masalah klien, serta pencapaian tujuan serta ketepatan intervensi keperawatan. (Gaffar 1999:67). Sesuai dengan rencana evaluasi maka sasaran evaluasi adalah sebagai berikut: 1) Proses asuhan keperawatan, berdasarkan kriteria atau rencana yang telah disusun. 2) Hasil keperawatan, berdasarkan kriteria keberhasilan yang telah dirumuskan dalam rencana evaluasi. Catatan ini berorientasi pada masalah dan disusun oleh anggota tim kesehatan. Setiap anggota menuliskan perkembangan yang terjadi pada lembaran yang sama, yaitu lembaran SOAP (subjective and Objective data, Analysis, Planning). 1) S (Data Subjektif) Data subjektif adalah data yang didapat dari klien secara langsung, misalnya dari keluhan atau perkataan klien. 2) O (Data Objektif) Data yang didapat melalui pengamatan dan pemeriksaan, seperti hasil pemeriksaan hasil fisik, hasil pemeriksaan laboratorium, hasil observasi, dan hasil pemeriksaan radiologi. 3) A (Analisis) Berdasarkan data subjektif dan objektif maka perawat melakukan analisis terhadap data tersebut. Analisis berfungsi untuk merumuskan kesimpulan mengenai perkembangan kondisi klien, menetapkan diagnosis baru (jika ada perubahan), dan mengevaluasi keefektifan tindakan yang telah dilakukan. 4) P (Perencanaan) Pada lembar ini perawat menuliskan rencana asuhan. Rencana asuhan dapat mencakup instruksi khusus untuk mengatasi masalah, mencari data tambahan, dan pendidikan bagi pasien dan keluarga. Rencana asuhan ini biasanya mengacu pada rencana sebelumnya, namun disertai beberapa perbaikan dan modifikasi. Evaluasi serta kriteria hasil yang diharapkan pada klien dengan anemia adalah mendemonstrasikan hilang dari nyeri dengan kriteria klien menyangkal nyeri, ekspresi wajah rileks; mendemonstrasikan koping efektif dengan penyakit kronis dengan kriteria mengungkapkan penerimaan terhadap diri pada situasi saat itu, mengungkapkan rencana pekerjaan realistis; mendemonstrasikan peningkatan toleransi pada aktivitas dengan kriteria melaporkan berkurangnya kelelahan dan dispnea bila melakukan rutin, frekuensi nadi 60-100 nadi per menit, dan frekuensi pernapasan 12-24 per menit istirahat serta mendemonstrasikan keinginan memenuhi rencana perawatan dengan kriteria mengungkapkan pemahaman tentang kondisi dan rencana tindakan, solusi terhadap anemia.