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Sunday, January 11, 2009

Foto Dada (Rontgen Thorak)

Pemeriksaan radiologi toraks merupakan upaya pengkajian klien dengan gangguan sistem kardiovaskular dan respirasi. Pengenalan kelainan yang penting pada foto thoraks sangat bermanfaat bagi perawat terutama dalam menghadapi keadaan akut sehingga perawat mampu untuk mmberikan intervensi yang benar maupun tindakan yang tepat. Sarana radiologis adalah semua alat yang menggunakan sinar-X atau pengion lainnya sebagai sarana diagnostik, misalnya pesawat sinar-X dan isotop. Foto thoraks bukan untuk menentukan diagnosa, tetapi merupakan salah satu data utama. TUJUAN Tujuan pemeriksan foto toraks : 1. Menilai adanya kelainan jantung, misalnya : kelainan letak jantung, pembesaran atrium atau ventrikel, pelebaran dan penyempitan aorta. 2. Menilai kelainan paru, misalnya edema paru, emfisema paru, tuberkulosis paru. 3. Menilai adanya perubahan pada struktur ekstrakardiak. a. Gangguan pada dinding toraks • Fraktur iga • Fraktur sternum b. Gangguan rongga pleura • Pneumotoraks • Hematotoraks • Efusi pleura c. Gangguan pada diafragma • Paralisis saraf frenikus d. Menilai letak alat-alat yang dimasukkan ke dalam organ di rongga toraks misalnya: EET, CVP, NGT, dan lain-lain. Macam Pemeriksaan : 1. Pemeriksaan Tanpa Kontras Pemeriksaan ini dipakai rutin dan sebagai pendahuluan yakni pembuatan radiografi thoraks dengan proyeksi Postero-Anterior (PA), Antero-Posterior (AP), dan lateral. Pemeriksaan lainnya yaitu pembuatan radilologi thoraks proyeksi oblique kanan dan kiri, dengan esofagus diisi barium, dan pemeriksaan tembus (fluoroskopi). Pemeriksaan tembus berguna untuk menilai pulsasi jantung dan gerakan diafragma. Pemeriksaan ini harus dibatasi penggunaannya karena besarnya radiasi yang dipancarkan. 2. Pemeriksaan Dengan Kontras Kontras dimasukkan melalui pembuluh darah ke dalam jantung diikuti pembuatan serial radiografi. Pemeriksaan ini berguna untuk melihat kelainan-kelainan yang terdapat dalam jantung seperti : dinding jantung sebelah dalam, katub jantung dan pembuluh darah besar, serta gambaran sirkulasi jantung paru. Pemeriksaan ini juga berguna untuk memberikan informasi keadaan jantung dan pembuluh darah sebelum dilakukan pembedahan. INTERPRETASI DASAR FOTO Hal-hal yang perlu diperhatikan dalam melakukan interprestasi foto thoraks yaitu: 1. Identitas: nama, nomor RM, tangal dan jam pembuatan foto, tindakan selanjutnya 2. Ketajaman sinar, apabila terlalu radiopaque (terlalu terang) atau terlalu gelap (radiolusen), maka foto harus diulang karena akan terjadi salah interprestasi Pengambilan foto yang baik: a. Bagian anterior terlihat sampai dengan iga 6-8 b. Bagian posterior terlihat sampai dengan iga 8-10 3. Dalam membaca foto rontgen, hal pertama yang perlu diperhatikan adalah densitas atau derajat tebalnya bayangan hitam pada film. Para radiolog menggolongkan adanya empat densitas yaitu: gas atau udara, air, lemak dan logam. Gas adalah substansi yang densitasnya paling rendah dan karena itu paling sedikit menyerap sinar. Dengan demikian struktur yang berisi udara seperti paru tampak sebagai bagian yang paling hitam. Densitas air tampak bersama jaringan lunak, otot, dan darah. Jantung akan tampak sebagai densitas air yang lebih terang dari densitas gas. Yang lebih terang tampak dalam foto adalah densitas lemak, dan yang paling terang tampak dala foto adalah logam. Yang akan tampak pada struktur tulang: adalah tulang rusuk, karena tulang rusuk paling menyerap banyak sinar x. Derajat Densitas GAS  Paru  Trakea  Bronki  Alveoli AIR  Jantung  Otot  Darah  Aorta  Diafragma  Pembuluh darah LEMAK  Tampak bercak lemak di daerah hilar LOGAM  Tulang rusuk  Skapula  Klavikula  Tulang belakang Sebuah foto torak biasanya diambil pada saat inspirasi. Foto yang diambil saat ekspirasi akan tampak kabur, sedangkan bayangan jantung akan tampak lebih besar dan ini akan menyebabkan intrepretasi yang salah. 4. Proyeksi foto thoraks Macam –macam proyeksi foto toraks a. ANTERIOR-POSTERIOR Pengambilan foto ini yang paling sering dilakukan pada pasien gawat, misalnya di ruang rawat darurat atau rawat intensif. Biasanya hasil foto ”portable” akan sedikit lebih buruk dibanding foto yang diambil di radiologi. Pada foto dapat dilihat tulang rusuk melandai ke bawah, jantung akan lebih besar dan semakin membesar apabila jarak fokus terhadap pasien lebih dekat. Skapula tampak di atas daerah paru. Cara mengambil pasien berbaring dengan film diletakkan di punggung pasien dan kamera berada kira-kira 1,5 meter di depan pasien. Akan lebih baik jika psien ditidurkan dalam posisi 450 dan pemotretan dilakukan saat inspirasi. b. POSTERIOR-ANTERIOR Posisi pengambilan ini biasanya dilakukan di bagian radilogi. Skapula tidak akan menutupi daerah paru. Besar jantung dapat diperkirakan dengan lebih mudah. Tulang rusuk anterior tidak tampak jelas, sedang rusuk di bagian belakang semuanya menuju ke arah tulang punggung. Pada posisi ini kamera berada di belakang pasien. c. POSISI BERBARING (SUPINE) Hal ini perlu dikakukan apabila pasien tidak dapat duduk. Pasien akan lebih sulit menarik nafas dalam, sehingga diafragma akan lebih tinggi. Jika ada cairan di paru atau di rongga pleura, maka hal ini tidak begitu jelas terlihat karena cairan cenderung hanya melapisi permukaan posterior paru. d. POSISI LATERAL Pengambilan posisi lateral tergantung atas indikasi apakah lateral kiri atau lateral kanan. Posisi ini dipakai pada pemeriksaan angiografi (untuk melihat kebocoran septum jantung, aneurisma aorta dan sebagainya). 5. POSISI/CENTERING Sternum akan tampak tegak lurus dengan tulang klavikula JANTUNG DAN MEDIASTINUM Sudut yang dibentuk oleh diafragma dengan bayangan jantung disebut sinus kardiofrenikus. Sinus kardiofrenikus kiri sering tampak suram oleh karena adanya bantalan lemak (Precardial Fat Pad). Tidak pada semua orang bantalan lemak ini terlihat nyata. Dimulai dari sinus kardiofrenikus kanan ke arah kranial, batas jantung di kanan bawah dibentuk oleh atrium kanan. Batas ini melengkung sedikit ke atas sampai pada suatu titik lengkungan dan dari titik ini batas jantung kanan atas hampir merupakan garis lurus ke atas bersambung dengan mediastimum superior. Batas atas ini dibentuk oleh vena kava superior. Ke sebelah dalam sedikit terdapat aorta ascendens yang melengkung ke medial kiri atas dan membentuk arkus aorta. Pada umumnya ventikel kanan tidak membentuk batas jantung pada proyeksi PA. Akan tetapi bila terjadi pembesaran ventrikel kanan yang berat maka ventrikel kanan ini mengambil bagian dalam pembentukan batas jantung kanan bawah. Batas jantung di sisi kiri atas dibentuk oleh arkus aorta yang menonjol ke sebelah kiri kolumna vertebralis. Di bawah arkus aorta terdapat batas yang melengkung ke dalam (konkaf) disebut pinggang jantung atau penonjolan dari arteri pulmonalis. Di bawah penonjolan arteri pulmonalis terdapat aurikel dari atrium kiri. Aurikel ini agak sulit dilihat karena biasanya tidak menonjol, kecuali bila terjadi pembesaran atrium kiri, seperti pada mitral stenosis. Atrium kiri tidak membentuk batas pada proyeksi PA, kecuali aurikelnya. Atrium kiri letaknya di belakang, kira-kira di bagian sepertiga tengah jantung. Di bawah aurikel ini batas kiri jantung dibentuk oleh ventrikel kiri yang merupakan lengkungan konveks ke bawah sampai ke sinus kardiorenikus kiri. Puncak lengkungan dari ventrikel kiri itu desebut sebagai apeks jantung, yang biasanya tampak beberapa sentimeter di atas diafragma kiri. Apeks jantung ini kadang-kadang tidak jelas dengan adanya bantyalan lemak yang lebar pada sinus kardiofrenikus kiri. Batas jantung tersebut akan tampak sebagai siluet ”bumps” dalam gambaran rontgen thoraks. a. Proyeksi Lateral Oleh karena sebagian besar dari jantung dan aorta terdapat di hemitoraks kiri, maka proyeksi ini sering dibuat dibuat secara lateral dengan menampilkan bahu kiri pada film dan arah sinar berjalan dari kanan ke kiri. Di belakang sternum, batas depan jantung dibentuk oleh ventrikel kanan yang merupakan lengkungan dari sudut diafragma depan ke arah kranial. Ke belakang, lengkungan ini menjadi lengkungan aorta. Batas dari aurikel kanan tidak begitu jelas, dan hampir segaris dengan lengkungan ventrikel kanan. Pada umumnya, bila bentuk dada dan sternum itu normal, ventrikel kanan akan menempel di bagian bawah dari sternum. Daerah di atas lengkungan ventrikel kanan adalah mediastinum anterior-superior. Bagian belakang dibentuk oleh atrium kiri, di bawah atrium kiri terdapat ventrikel kiri yang merupakan batas belakang bawah jantung (di depan kolumna vertebralis). Aorta ventrikel kiri hampir berhimpit dengan vena kava inferior. Salah satu cara untuk menilai pembesaran jantung adalah dengan mengukur perbandingan antara ukuran transversal jantung dengan lebarnya dada, dengan menggunakan radiografi polos toraks proyeksi PA. Cara pengukurannya adalah sebagai berikut: Ditarik garis M yang berjalan di tengah-tengah kolumna vertebralis torakalis. Garis A adalah jarak antara M dengan batas jantung sisi kanan yang terjauh. Garis B adalah jarak antara M dengan batas kiri jantung yang terjauh. Garis transversal C ditarik dari dinding toraks sisi kanan ke dinding toraks sisi kiri. Garis ini melalui sinus kardiofrenikus kanan. Bila sinus-sinus kardiofrenikus ini tidak sama tingginya, maka garis C ditarik melalui pertengahan antara kedua sinus itu. Cara lain yaitu: menarik garis C ini dari sinus kardiofrenikus kanan ke sinus kardiofrenikus kiri. Perbedaan pengukuran ini tidak terlalu besar sehingga dapat dipakai semuanya. Rasio kardio-toraks = (a + b): c x 100% Pada orang dewasa dengan bentuk tubuh yang normal, rasio kardio-toraks berkisar 45-50%. Faktor-faktor lain yang perlu dipertimbangkan pada pengukuran ini adalah: orang gemuk dan pendek, usia, bentuk toraks, letak diafragma dan kelainan pada paru-paru yang mungkin mempengaruhi letak jantung. Pembesaran pada bayangan jantung dapat disebabkan oleh : a. Kelainan perikardium (efusi perikardial) b. Kelainan pada miokard c. Hipertofi dan dilatasi ventrikel atau atrium karena kelainan katup atau kebocoran septum jantung. Pembesaran Atrium dan Ventrikel pada Radiografi polos a. Pembesaran atrium kanan Pada proyeksi PA bagian bawah jantung pada sisi kanan lebih banyak menonjol ke lateral kanan. Garis A menjadi lebih besar dari 1/3 C1. Sudut kardiofrenikus menjadi lebih besar. Contoh: ASD. b. Pembesaran atrium kiri Pada proyeksi PA, terlihat batas kembar (double countour) pada sisi kanan bawah. Batas ini dibentuk oleh batas atrium kiri dilihat sebagai penonjolan di bawah segmen pulmonal. Ventrikel kanan tampak membesar Perubahan letak esofagus ke sisi posterior Kalsifikasi katup mitral Mikrolithiasis pulmonar (kondisi kronik) Contoh: insufisiensi/ stenosis katup mitral. c. Pembesaran ventrikel kanan Pada proyeksi PA, apeks bergeser ke lateral atas. Contoh: Pulmonal atresi/ stenosis. d. Pembesaran ventrikel kiri Pada proyeksi PA, jantung membesar ke kiri dengan apeks menurun berada di bawah diafragma kiri. Bila aorta membesar maka pinggang jantung tampak lebih dalam dari biasa. Contoh : stenosis katup aorta. PENILAIAN PEMBULUH DARAH PARU Hilus adalah tempat arteri pulmonalis, vena pulmonalis, bronkus dan saluran limfe masuk ke dalam paru. Hilus kanan letaknya kira-kira di pertengahan dari jarak apeks paru ke diafragma kanan. Hilus kiri letaknya lebih tinggi sedikit. Dari hilus ini dapat diikuti cabang-cabang dari arteri pulmonalis di dalam paru-paru yang makin kecil ke arah perifer. Vena pulmonalis tidak selalu terlihat pada radiografi polos, kecuali pada mitral stenosis. Pembuluh darah paru di lapangan bawah tampak lebih banyak dari pada lapangan paru atas. Trakea tampak jelas sebagai garis tengah dengan densitas film yang lebih sedikit. Percabangan trakea terdapat pada torkal ke-5. Perubahan pada paru 1. Edema Paru Edema paru dapat terjadi karena beberapa sebab yaitu: • Tekanan kapiler meningkat • Permeabilitas pembuluh darah meningkat • Perubahan tekanan onkotik darah Edema interstitial menyebabkan bercak-bercak tipis di paru, sehingga gambaran radiolusensi paru berubah menjadi suram. Di daerah hilus, bercak-bercak ini sering terjadi perkabutan tipis, sehingga batas-batas pembuluh darah menjadi kabur. Edema paru alveolar menyebabkan perselubungan yang lebih tebal. Perselubungan ini seringkali terjadi di lapangan paru perihilar kanan dan kiri, bentuknya menyerupai sayap kupu-kupu. 2. Cairan dalam kavum pleura Ciri-ciri pada foto toraks: • Bayangan opaque pada paru bagain bawah. • Tidak terlihat sudut kostofrenikus 3. Kolaps paru/atelektasis Ciri-ciri pada foto toraks: • Bayangan opaque karena paru tidak mendapat udara. Batas tegas • Trakea tertarik ke sisi yang sakit • Rusuk pada sisi sakit lebih dekat • Tidak ada sudut costofrenik 4. Pneumotoraks Ciri-ciri pada foto toraks: • Bayangan radiolusen • Trakea terdorong ke arah yang sehat • Mempunyai batas tegas • Vaskularisasi tidak terlihat. 5. Empiema 6. ARDS TANGGUNG JAWAB PERAWAT DALAM PEMERIKSAAN RADIOLOGI Jika ada seseorang pasien akan dilakukan pemeriksaan foto toraks, maka tanggung jawab perawat adalah : 1. Jelaskan apa yang akan dilakukan pada pasien dan mengapa hal ini dilakukan. 2. Coba menenangkan pasien sementara mendudukkannya untuk mengambil foto pada posisi tegak. 3. Perawat harus selalu mendampingi guna membantu radigrafer, agar tidak terjadi hal-hal yang tidak diinginkan (ETT lepas, dll). 4. Perhatikan agar tidak terjadi tegangan pada salah satu kabel dan tidak ada salah satu kabelpun yang terlepas. 5. Usahakan tidak ada yang menghalangi lempeng foto agar dapat diambil foto dengan jelas. 6. Pertimbangkan apakah perlu mendudukkan seseorang pasien yang mengalami hipotensi, mungkin dapat dibuat foto pada posisi berbaring. 7. Jika pasien lumpuh, ia harus selalu dibantu karena pada pasien tidak ada reflek. Perhatikan posisi kepala dan leher untuk mencegah terjadinya fraktur.

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