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Lose

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Batasan-Batasan
1. Ikterus Fisiologis
Ikterus pada neonatus tidak selamanya patologis. Ikterus fisiologis adalah Ikterus yang memiliki karakteristik sebagai berikut (Hanifa, 1987):
• Timbul pada hari kedua-ketiga
• Kadar Biluirubin Indirek setelah 2 x 24 jam tidak melewati 15 mg% pada neonatus cukup bulan dan 10 mg % pada kurang bulan.
• Kecepatan peningkatan kadar Bilirubin tak melebihi 5 mg % per hari
• Kadar Bilirubin direk kurang dari 1 mg %
• Ikterus hilang pada 10 hari pertama
• Tidak terbukti mempunyai hubungan dengan keadan patologis tertentu
2. Ikterus Patologis/Hiperbilirubinemia
Adalah suatu keadaan dimana kadar Bilirubin dalam darah mencapai suatu nilai yang mempunyai potensi untuk menimbulkan Kern Ikterus kalau tidak ditanggulangi dengan baik, atau mempunyai hubungan dengan keadaan yang patologis. Brown menetapkan Hiperbilirubinemia bila kadar Bilirubin mencapai 12 mg% pada cukup bulan, dan 15 mg % pada bayi kurang bulan. Utelly menetapkan 10 mg% dan 15 mg%.
3. Kern Ikterus
Adalah suatu kerusakan otak akibat perlengketan Bilirubin Indirek pada otak terutama pada Korpus Striatum, Talamus, Nukleus Subtalamus, Hipokampus, Nukleus merah , dan Nukleus pada dasar Ventrikulus IV.
D. Etiologi
1. Peningkatan produksi :
• Hemolisis, misal pada Inkompatibilitas yang terjadi bila terdapat ketidaksesuaian golongan darah dan anak pada penggolongan Rhesus dan ABO.
• Pendarahan tertutup misalnya pada trauma kelahiran.
• Ikatan Bilirubin dengan protein terganggu seperti gangguan metabolik yang terdapat pada bayi Hipoksia atau Asidosis .
• Defisiensi G6PD/ Glukosa 6 Phospat Dehidrogenase.
• Ikterus ASI yang disebabkan oleh dikeluarkannya pregnan 3 (alfa), 20 (beta) , diol (steroid).
• Kurangnya Enzim Glukoronil Transeferase , sehingga kadar Bilirubin Indirek meningkat misalnya pada berat lahir rendah.
• Kelainan kongenital (Rotor Sindrome) dan Dubin Hiperbilirubinemia.
2. Gangguan transportasi akibat penurunan kapasitas pengangkutan misalnya pada Hipoalbuminemia atau karena pengaruh obat-obat tertentu misalnya Sulfadiasine.
3. Gangguan fungsi Hati yang disebabkan oleh beberapa mikroorganisme atau toksion yang dapat langsung merusak sel hati dan darah merah seperti Infeksi , Toksoplasmosis, Siphilis.
4. Gangguan ekskresi yang terjadi intra atau ekstra Hepatik.
5. Peningkatan sirkulasi Enterohepatik misalnya pada Ileus Obstruktif
E . Metabolisme Bilirubin
Segera setelah lahir bayi harus mengkonjugasi Bilirubin (merubah Bilirubin yang larut dalam lemak menjadi Bilirubin yang mudah larut dalam air) di dalam hati. Frekuensi dan jumlah konjugasi tergantung dari besarnya hemolisis dan kematangan hati, serta jumlah tempat ikatan Albumin (Albumin binding site).
Pada bayi yang normal dan sehat serta cukup bulan, hatinya sudah matang dan menghasilkan Enzim Glukoronil Transferase yang memadai sehingga serum Bilirubin tidak mencapai tingkat patologis.
Diagram Metabolisme Bilirubin
ERITROSIT
HEMOGLOBIN
HEM
GLOBIN
BESI/FE
BILIRUBIN INDIREK
( tidak larut dalal air )
Terjadi pada
Limpha, Makofag
BILIRUBIN BERIKATAN DENGAN ALBUMIN
Terjadi dalam plasma darah
MELALUI HATI
BILIRUBIN BERIKATAN DENGAN GLUKORONAT/ GULA RESIDU BILIRUBIN DIREK
( larut dalam air )
Hati
BILIRUBIN DIREK DIEKSRESI KE KANDUNG EMPEDU
Melalui
Duktus Billiaris
KANDUNG EMPEDU KE DEUDENUM
BILIRUBIN DIREK DI EKSKRESI MELALUI URINE & FECES
F. Patofisiologi Hiperbilirubinemia
Peningkatan kadar Bilirubin tubuh dapat terjadi pada beberapa keadaan . Kejadian yang sering ditemukan adalah apabila terdapat penambahan beban Bilirubin pada sel Hepar yang berlebihan. Hal ini dapat ditemukan bila terdapat peningkatan penghancuran Eritrosit, Polisitemia.
Gangguan pemecahan Bilirubin plasma juga dapat menimbulkan peningkatan kadar Bilirubin tubuh. Hal ini dapat terjadi apabila kadar protein Y dan Z berkurang, atau pada bayi Hipoksia, Asidosis. Keadaan lain yang memperlihatkan peningkatan kadar Bilirubin adalah apabila ditemukan gangguan konjugasi Hepar atau neonatus yang mengalami gangguan ekskresi misalnya sumbatan saluran empedu.
Pada derajat tertentu Bilirubin ini akan bersifat toksik dan merusak jaringan tubuh. Toksisitas terutama ditemukan pada Bilirubin Indirek yang bersifat sukar larut dalam air tapi mudah larut dalam lemak. sifat ini memungkinkan terjadinya efek patologis pada sel otak apabila Bilirubin tadi dapat menembus sawar darah otak. Kelainan yang terjadi pada otak disebut Kernikterus. Pada umumnya dianggap bahwa kelainan pada saraf pusat tersebut mungkin akan timbul apabila kadar Bilirubin Indirek lebih dari 20 mg/dl.
Mudah tidaknya kadar Bilirubin melewati sawar darah otak ternyata tidak hanya tergantung pada keadaan neonatus. Bilirubin Indirek akan mudah melalui sawar darah otak apabila bayi terdapat keadaan Berat Badan Lahir Rendah , Hipoksia, dan Hipoglikemia ( AH, Markum,1991).
G. Penata Laksanaan Medis
Berdasarkan pada penyebabnya, maka manejemen bayi dengan Hiperbilirubinemia diarahkan untuk mencegah anemia dan membatasi efek dari Hiperbilirubinemia. Pengobatan mempunyai tujuan :
1. Menghilangkan Anemia
2. Menghilangkan Antibodi Maternal dan Eritrosit Tersensitisasi
3. Meningkatkan Badan Serum Albumin
4. Menurunkan Serum Bilirubin
Metode therapi pada Hiperbilirubinemia meliputi : Fototerapi, Transfusi Pengganti, Infus Albumin dan Therapi Obat.
Fototherapi
Fototherapi dapat digunakan sendiri atau dikombinasi dengan Transfusi Pengganti untuk menurunkan Bilirubin. Memaparkan neonatus pada cahaya dengan intensitas yang tinggi ( a boun of fluorencent light bulbs or bulbs in the blue-light spectrum) akan menurunkan Bilirubin dalam kulit. Fototherapi menurunkan kadar Bilirubin dengan cara memfasilitasi eksresi Biliar Bilirubin tak terkonjugasi. Hal ini terjadi jika cahaya yang diabsorsi jaringan mengubah Bilirubin tak terkonjugasi menjadi dua isomer yang disebut Fotobilirubin. Fotobilirubin bergerak dari jaringan ke pembuluh darah melalui mekanisme difusi. Di dalam darah Fotobilirubin berikatan dengan Albumin dan dikirim ke Hati. Fotobilirubin kemudian bergerak ke Empedu dan diekskresi ke dalam Deodenum untuk dibuang bersama feses tanpa proses konjugasi oleh Hati (Avery dan Taeusch 1984). Hasil Fotodegradasi terbentuk ketika sinar mengoksidasi Bilirubin dapat dikeluarkan melalui urine.
Fototherapi mempunyai peranan dalam pencegahan peningkatan kadar Bilirubin, tetapi tidak dapat mengubah penyebab Kekuningan dan Hemolisis dapat menyebabkan Anemia.
Secara umum Fototherapi harus diberikan pada kadar Bilirubin Indirek 4 -5 mg / dl. Neonatus yang sakit dengan berat badan kurang dari 1000 gram harus di Fototherapi dengan konsentrasi Bilirubun 5 mg / dl. Beberapa ilmuan mengarahkan untuk memberikan Fototherapi Propilaksis pada 24 jam pertama pada Bayi Resiko Tinggi dan Berat Badan Lahir Rendah.
Tranfusi Pengganti
Transfusi Pengganti atau Imediat diindikasikan adanya faktor-faktor :
1. Titer anti Rh lebih dari 1 : 16 pada ibu.
2. Penyakit Hemolisis berat pada bayi baru lahir.
3. Penyakit Hemolisis pada bayi saat lahir perdarahan atau 24 jam pertama.
4. Tes Coombs Positif
5. Kadar Bilirubin Direk lebih besar 3,5 mg / dl pada minggu pertama.
6. Serum Bilirubin Indirek lebih dari 20 mg / dl pada 48 jam pertama.
7. Hemoglobin kurang dari 12 gr / dl.
8. Bayi dengan Hidrops saat lahir.
9. Bayi pada resiko terjadi Kern Ikterus.
Transfusi Pengganti digunakan untuk :
1. Mengatasi Anemia sel darah merah yang tidak Suseptible (rentan) terhadap sel darah merah terhadap Antibodi Maternal.
2. Menghilangkan sel darah merah untuk yang Tersensitisasi (kepekaan)
3. Menghilangkan Serum Bilirubin
4. Meningkatkan Albumin bebas Bilirubin dan meningkatkan keterikatan dengan Bilirubin
Pada Rh Inkomptabiliti diperlukan transfusi darah golongan O segera (kurang dari 2 hari), Rh negatif whole blood. Darah yang dipilih tidak mengandung antigen A dan antigen B yang pendek. setiap 4 – 8 jam kadar Bilirubin harus dicek. Hemoglobin harus diperiksa setiap hari sampai stabil.
Therapi Obat
Phenobarbital dapat menstimulasi hati untuk menghasilkan enzim yang meningkatkan konjugasi Bilirubin dan mengekresinya. Obat ini efektif baik diberikan pada ibu hamil untuk beberapa hari sampai beberapa minggu sebelum melahirkan. Penggunaan penobarbital pada post natal masih menjadi pertentangan karena efek sampingnya (letargi).
Colistrisin dapat mengurangi Bilirubin dengan mengeluarkannya lewat urine sehingga menurunkan siklus Enterohepatika.
Penggolongan Hiperbilirubinemia berdasarkan saat terjadi Ikterus:
1. Ikterus yang timbul pada 24 jam pertama.
Penyebab Ikterus terjadi pada 24 jam pertama menurut besarnya kemungkinan dapat disusun sbb:
• Inkomptabilitas darah Rh, ABO atau golongan lain.
• Infeksi Intra Uterin (Virus, Toksoplasma, Siphilis dan kadang-kadang Bakteri)
• Kadang-kadang oleh Defisiensi Enzim G6PD.
Pemeriksaan yang perlu dilakukan:
• Kadar Bilirubin Serum berkala.
• Darah tepi lengkap.
• Golongan darah ibu dan bayi.
• Test Coombs.
• Pemeriksaan skrining defisiensi G6PD, biakan darah atau biopsi Hepar bila perlu.
2. Ikterus yang timbul 24 – 72 jam sesudah lahir.
• Biasanya Ikterus fisiologis.
• Masih ada kemungkinan inkompatibilitas darah ABO atau Rh, atau golongan lain. Hal ini diduga kalau kenaikan kadar Bilirubin cepat misalnya melebihi 5mg% per 24 jam.
• Defisiensi Enzim G6PD atau Enzim Eritrosit lain juga masih mungkin.
• Polisetimia.
• Hemolisis perdarahan tertutup ( pendarahan subaponeurosis, pendarahan Hepar, sub kapsula dll).
Bila keadaan bayi baik dan peningkatannya cepat maka pemeriksaan yang perlu dilakukan:
• Pemeriksaan darah tepi.
• Pemeriksaan darah Bilirubin berkala.
• Pemeriksaan skrining Enzim G6PD.
• Pemeriksaan lain bila perlu.
3. Ikterus yang timbul sesudah 72 jam pertama sampai akhir minggu pertama.
• Sepsis.
• Dehidrasi dan Asidosis.
• Defisiensi Enzim G6PD.
• Pengaruh obat-obat.
• Sindroma Criggler-Najjar, Sindroma Gilbert.
4. Ikterus yang timbul pada akhir minggu pertama dan selanjutnya:
• Karena ikterus obstruktif.
• Hipotiroidisme
• Breast milk Jaundice.
• Infeksi.
• Hepatitis Neonatal.
• Galaktosemia.
Pemeriksaan laboratorium yang perlu dilakukan:
• Pemeriksaan Bilirubin berkala.
• Pemeriksaan darah tepi.
• Skrining Enzim G6PD.
• Biakan darah, biopsi Hepar bila ada indikasi.
ASUHAN KEPERAWATAN
Untuk memberikan keperawatan yang paripurna digunakan proses keperawatan yang meliputi Pengkajian, Perencanaan, Pelaksanaan dan Evaluasi.
Pengkajian
1. Riwayat orang tua :
Ketidakseimbangan golongan darah ibu dan anak seperti Rh, ABO, Polisitemia, Infeksi, Hematoma, Obstruksi Pencernaan dan ASI.
2. Pemeriksaan Fisik :
Kuning, Pallor Konvulsi, Letargi, Hipotonik, menangis melengking, refleks menyusui yang lemah, Iritabilitas.
3. Pengkajian Psikososial :
Dampak sakit anak pada hubungan dengan orang tua, apakah orang tua merasa bersalah, masalah Bonding, perpisahan dengan anak.
4. Pengetahuan Keluarga meliputi :
Penyebab penyakit dan pengobatan, perawatan lebih lanjut, apakah mengenal keluarga lain yang memiliki yang sama, tingkat pendidikan, kemampuan mempelajari Hiperbilirubinemia (Cindy Smith Greenberg. 1988)
2. Diagnosa, Tujuan , dan Intervensi
Berdasarkan pengkajian di atas dapat diidentifikasikan masalah yang memberi gambaran keadaan kesehatan klien dan memungkinkan menyusun perencanaan asuhan keperawatan. Masalah yang diidentifikasi ditetapkan sebagai diagnosa keperawatan melalui analisa dan interpretasi data yang diperoleh.
1. Diagnosa Keperawatan : Kurangnya volume cairan sehubungan dengan tidak adekuatnya intake cairan, fototherapi, dan diare.
Tujuan : Cairan tubuh neonatus adekuat
Intervensi : Catat jumlah dan kualitas feses, pantau turgor kulit, pantau intake output, beri air diantara menyusui atau memberi botol.
2. Diagnosa Keperawatan : Gangguan suhu tubuh (hipertermi) sehubungan dengan efek fototerapi
Tujuan : Kestabilan suhu tubuh bayi dapat dipertahankan C, cek tanda-tanda vital tiap 2 jam. – 37Intervensi : Beri suhu lingkungan yang netral, pertahankan suhu antara 35,5
3. Diagnosa Keperawatan : Gangguan integritas kulit sehubungan dengan hiperbilirubinemia dan diare
Tujuan : Keutuhan kulit bayi dapat dipertahankan
Intervensi : Kaji warna kulit tiap 8 jam, pantau bilirubin direk dan indirek , rubah posisi setiap 2 jam, masase daerah yang menonjol, jaga kebersihan kulit dan kelembabannya.
4. Diagnosa Keperawatan : Gangguan parenting sehubungan dengan pemisahan
Tujuan : Orang tua dan bayi menunjukan tingkah laku “Attachment” , orang tua dapat mengekspresikan ketidak mengertian proses Bounding.
Intervensi : Bawa bayi ke ibu untuk disusui, buka tutup mata saat disusui, untuk stimulasi sosial dengan ibu, anjurkan orangtua untuk mengajak bicara anaknya, libatkan orang tua dalam perawatan bila memungkinkan, dorong orang tua mengekspresikan perasaannya.
5. Diagnosa Keperawatan : Kecemasan meningkat sehubungan dengan therapi yang diberikan pada bayi.
Tujuan : Orang tua mengerti tentang perawatan, dapat mengidentifikasi gejala-gejala untuk menyampaikan pada tim kesehatan
Intervensi :
Kaji pengetahuan keluarga klien, beri pendidikan kesehatan penyebab dari kuning, proses terapi dan perawatannya. Beri pendidikan kesehatan mengenai cara perawatan bayi dirumah.
6. Diagnosa Keperawatan : Potensial trauma sehubungan dengan efek fototherapi
Tujuan : Neonatus akan berkembang tanpa disertai tanda-tanda gangguan akibat fototherapi
Intervensi :
Tempatkan neonatus pada jarak 45 cm dari sumber cahaya, biarkan neonatus dalam keadaan telanjang kecuali mata dan daerah genetal serta bokong ditutup dengan kain yang dapat memantulkan cahaya; usahakan agar penutup mata tida menutupi hidung dan bibir; matikan lampu, buka penutup mata untuk mengkaji adanya konjungtivitis tiap 8 jam; buka penutup mata setiap akan disusukan; ajak bicara dan beri sentuhan setiap memberikan perawatan.
7. Diagnosa Keperawatan : Potensial trauma sehubungan dengan tranfusi tukar
Tujuan : Tranfusi tukar dapat dilakukan tanpa komplikasi
Intervensi :
Catat kondisi umbilikal jika vena umbilikal yang digunakan; basahi umbilikal dengan NaCl selama 30 menit sebelum melakukan tindakan, neonatus puasa 4 jam sebelum tindakan, pertahankan suhu tubuh bayi, catat jenis darah ibu dan Rhesus serta darah yang akan ditranfusikan adalah darah segar; pantau tanda-tanda vital; selama dan sesudah tranfusi; siapkan suction bila diperlukan; amati adanya ganguan cairan dan elektrolit; apnoe, bradikardi, kejang; monitor pemeriksaan laboratorium sesuai program.
Aplikasi Discharge Planing.
Pertumbuhan dan perkembangan serta perubahan kebutuhan bayi dengan hiperbilirubin (seperti rangsangan, latihan, dan kontak sosial) selalu menjadi tanggung jawab orang tua dalam memenuhinya dengan mengikuti aturan dan gambaran yang diberikan selama perawatan di Rumah Sakit dan perawatan lanjutan dirumah.
Faktor yang harus disampaikan agar ibu dapat melakukan tindakan yang terbaik dalam perawatan bayi hiperbilirubinimea (warley &Wong, 1994):
1. Anjurkan ibu mengungkapkan/melaporkan bila bayi mengalami gangguan-gangguan kesadaran seperti : kejang-kejang, gelisah, apatis, nafsu menyusui menurun.
2. Anjurkan ibu untuk menggunakan alat pompa susu selama beberapa hari untuk mempertahankan kelancaran air susu.
3. Memberikan penjelasan tentang prosedur fototherapi pengganti untuk menurunkan kadar bilirubin bayi.
4. Menasehatkan pada ibu untuk mempertimbangkan pemberhentian ASI dalam hal mencegah peningkatan bilirubin.
5. Mengajarkan tentang perawatan kulit :
• Memandikan dengan sabun yang lembut dan air hangat.
• Siapkan alat untuk membersihkan mata, mulut, daerah perineal dan daerah sekitar kulit yang rusak.
• Gunakan pelembab kulit setelah dibersihkan untuk mempertahankan kelembaban kulit.
• Hindari pakaian bayi yang menggunakan perekat di kulit.
• Hindari penggunaan bedak pada lipatan paha dan tubuh karena dapat mengakibatkan lecet karena gesekan
• Melihat faktor resiko yang dapat menyebabkan kerusakan kulit seperti penekanan yang lama, garukan .
• Bebaskan kulit dari alat tenun yang basah seperti: popok yang basah karena bab dan bak.
• Melakukan pengkajian yang ketat tentang status gizi bayi seperti : turgor kulit, capilari reffil.
Hal lain yang perlu diperhatikan adalah :
1. Cara memandikan bayi dengan air hangat celsius)(37 -38
2. Perawatan tali pusat / umbilikus
3. Mengganti popok dan pakaian bayi
4. Menangis merupakan suatu komunikasi jika bayi tidak nyaman, bosan, kontak dengan sesuatu yang baru
5. Temperatur / suhu
6. Pernapasan
7. Cara menyusui
8. Eliminasi
9. Perawatan sirkumsisi
10. Imunisasi
11. Tanda-tanda dan gejala penyakit, misalnya :
• letargi ( bayi sulit dibangunkan )
• demam ( suhu > celsius)37
• muntah (sebagian besar atau seluruh makanan sebanyak 2 x)
• diare ( lebih dari 3 x)
• tidak ada nafsu makan.
12. Keamanan
• Mencegah bayi dari trauma seperti; kejatuhan benda tajam (pisau, gunting) yang mudah dijangkau oleh bayi / balita.
• Mencegah benda panas, listrik, dan lainnya
• Menjaga keamanan bayi selama perjalanan dengan menggunakan mobil atau sarana lainnya.
• Pengawasan yang ketat terhadap bayi oleh saudara – saudaranya.

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How to Lose Weight

...money and efforts on quick-result promising diets to  lose weight. However, by following some simple steps, you can definitely obtain successful results on weight loss and become slimmer.             The first step is absolutely motivation. Once you’ve made  up your mind, you should act determinedly. Undoubtedly, determination is the key to success. Even if all conditions are provided completely, lack of motivation results unsuccessfully. For instance, I recently read that a 116 kg-weighted young Mexican boy’s dream was to become a basketball player. You may reckon this looks unrealizable and impossible to attain.  But he achieved his goal, he is now 67 kg and plays in the local basketball team.              After being motivated completely to your goal, the second step is to provide a regular life with healthy diet. Several researches show us that sleeping more than 6 hours causes a gain of weight for adults. Likewise, eating more than your body needs is also an important reason to get weight. Avoiding food with fat and sugar will be very efficient to help you to lose weight. Changing  your life style might be difficult at the beginning, but in time, when you start to lose your first kilos, you’ll get used to it.              The last step to support your healthy life and to keep your weight at the desired level, is to join sport activities according to personal interest.  It’s common that people who try to lose weight or who already succeeded in losing their extra......

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