NURSING CARE of patients With Gastroiintestinal System Disorder

Case 1; Ilustration Anda adalah seorang perawat di ruang emergency yang sedang jaga malam. Seorang pasien 32 tahun datang diantar oleh beberapa orang anggota keluarganya dengan cara dipapah. Lima 5 orang anggota Keluarga ketika masuk UGD kelihatan panik dan tergesa-gesa. Keluarga mengatakan “Adik saya mengalami muntah darah sejak 2 jam yang lalu dengan jumlah banyak. Dia mengeluh pusing dan badannya agak lemas”. Dari pengamatan sepintas yang anda lakukan, pasien tampak pucat dan di pakaian yang dipakainya tampak cukup banyak bercak darah.

QUESTIONS

Setelah pasien ditidurkan di Branchart, Apa yang akan anda lakukan pada pasien dan keluarganya. Sebutkan step tindakan Anda.

Apa saja yang perlu Anda tanyakan pada pasien dan keluarganya dan apa kemungkinan jawaban/data yang Anda dapatkan. Bagaimana cara anda bertanya (peragakan).

Pada pemeriksaan fisik, apa saja yang perlu Anda periksa dan apa kemungkinan hasil pemeriksaannya. (Peragakan caranya). Apa yang bisa Anda simpulkan dari hasil pemeriksaan fisik tersebut (kemungkinan)

Pemeriksaan penunjang/diagnostic apa yang diperlukan pada pasien tersebut? apa tujuan pemeriksaan tersebut dan apa kemungkinan hasilnya?

Sebelum Anda melakukan TIndakan pemeriksaan diagnostic tersebut apa yang perlu Anda siapkan dan bagaimana penjelasan kepada pasien dan keluarganya (peragakan)

Dari hasil anamnesa dan pemeriksaan fisik serta pemeriksaan penunjang Masalah keperawatan apa yang mungkin muncul pada pasien Anda tersebut

Apa masalah/diagnosa keperawatan yang mungkin muncul. Berikan alasan Anda

Apa rencana tindakan yang akan Anda Lakukan.

Sebutkan dan jelaskan, apa komplikasi yang mungkin muncul pada pasien tersebut

Dokter mendiagnosa pasien dengan Hematomisi Melena

Dari hasil pemeriksaan darah pasien bergolongan darah A dan memerlukan tranfusi darah. Kenapa pasien tersebut harus mendapat tranfusi darah?

Setelah Menghubungi PMI, ternyata stok darah Golongan A tidak Ada. Apa yang Anda Lakukan?

Apakah pasien perlu dipasang infuse? Pilihan cairan infuse yang bisa digunakan apa? Berapa volume cairan yang diberikan? Berapa tetesannya?

Pasien akan dipasang NGT? Apa tujuan pemasangan, bagaimana mekanisme fungsi dari NGT tersebut

Setelah Anda Melakukan serangkaian Tindakan yang Anda rencanakan dan diinstruksikan oleh dokter, apa yang perlu Anda Observasi dan evaluasi. Berapa lama

Apakah pasien harus di MRS-kan? Kira-kira apa alasan ketikan MRS atau dipulangkan.

Penjelasan apa yang Anda akan berikan kepada pasien dan keluarga, seandainya pasien di MRS-kan atau dipulangkan,.

Let You Discuss Those Questions and Find out

the Answer Learn the literature that appropriate

at all Analyze the patient situation and

condition Ask the experienced health service

(Nurses and doctors) Discuss with your group Choose the possibility answers

You Will Become the good Nurses

NURSING ASSESSMENT AND DIAGNOSIS Gastroiintestiinal System

Subjective Data Health History Medications Nutritional

Assessment Family History Cultural

Influences

Physical assessment

Diagnostic Tests Laboratory tests Radiographic tests Endoscopy Gastric analysis Cytological studies Magnetic resonance

imaging

Objective Data

SUBJECTIVE DATA

Health History Demographic data is obtained,

including travel Focus and common symptoms to GI

dysfunction Pain Indigestion Intestinal Gas Nausea and Vomiting Change in Bowel Habits and Stool

Characteristics History of any gastrointestinal

diseases

Symptoms of GI dysfunction Where it is, How it feels, Aggravating and alleviating factors, Timing, Severity, useful data for associated

symptoms, and Perception by the patient of the problem

PAIN Pain can be a major symptom of GI

disease. The character, duration, pattern,

frequency, location, distribution of referred pain and time of the pain vary greatly depending on the underlying cause.

Other factors, such as meals, rest, defecation, and vascular disorders, may directly affect this pain.

Indigestion Upper abdominal discomfort or distress

associated with eating The most common symptom of patients

with GI dysfunction Indigestion can result from disturbed

nervous system control of the stomach Fatty foods tend to cause the most

discomfort Coarse vegetables and highly seasoned

foods can also cause considerable distress

Intestinal Gas The accumulation of gas in the GI tract may

result in belching (the expulsion of gas from the stomach through the mouth) or flatulence (the expulsion of gas from the rectum).

It is through belching that swallowed air is expelled quickly when it reaches the stomach.

Usually, gases in the small intestine pass into the colon and are released as flatus.

Patients often complain of bloating, distention, or being “full of gas.” Excessive flatulence may be a symptom of gallbladder disease or food intolerance.

Nausea and Vomiting Vomiting is usually preceded by nausea,

which can be triggered by odors, activity, or food intake.

The emesis, or vomitus, may vary in color and content.

It may contain undigested food particles or blood (hematemesis).

When vomiting occurs soon after hemorrhage, The emesis is bright red.

If blood has been retained in the stomach, it takes on a coffee-ground appearance because of the action of the digestive enzymes.

Change in Bowel Habits and Stool Characteristics Changes in bowel habits may signal

colon disease Diarrhea- constipation?? Diarrhea is sometimes associated

with abdominal pain or cramping and nausea or vomiting.

Constipation may be associated with anal discomfort and rectal bleeding

The characteristics of the stool can vary greatly. Stool is normally light to dark brown

Blood in the stool can present in various ways and must be investigated.

Melena???

History of any gastrointestinal diseases History of any gastrointestinal diseases,

Ulcers, cancer, Crohn’s disease, Or colitis; Or an unexplained weight loss or gain. Etc

Information about previous GI surgeries is obtained.

Signs or symptoms of disease, (also noted) Bloody or tarry stools, Rectal bleeding, stomach pain, or abdominal pain,.

Medications The patient is asked about

medication use such as nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, vitamins, laxatives, enemas, or antacids, Etc

Heavy use of medications that can cause irritation and bleeding in the GI tract

Nutritional Assessment A diet history should include :

Usual foods and fluids, Allergies, Appetite patterns, Swallowing difficulty, and use of nutritional and herbal

supplements

Family History Some GI problems such as colon

cancer are thought to be hereditary

OBJECTIVE DATA

Objective Data Physical assessment Diagnostic Tests

Laboratory tests Radiographic tests Endoscopy Gastric analysis Cytological studies Magnetic resonance imaging

PHYSICAL ASSESSMENT(REVIEW GI SYSTEM)

General appearance Skin Head Abdomen Psychological factor

General appearance Aktivitas Motorik Posisi tubuh Perubahan status nutrisi : Berat

Badan dan Penampilan status kesehatan

Skin Warna (Ikterik, sianosis, pucat) Turgor Tekstur (berminyak atau kering) Kondisi dermatologis

Head Warna Sklera Mata Cekung Bau nafas Kondisi gigi Kondisi lidah dan mukosa bukal

Abdomen

Abdomen Inspeksi Auskultasi Perkusi Palpasi

Ukuran-Bentuk-Perubahan warna kulit- tonjolan yang nampak-jaringan

parut-fistula-pengembangan respirasi yang terbatas-lipatan kulit

yang berlebihan-Etc

DIAGNOSTIC TESTS Laboratory tests Radiographic tests Endoscopy Gastric analysis Cytological studies Magnetic resonance imaging

Laboratory tests Blood Test

The complete blood cell count (CBC) reveals if anemia or infection are present. Anemia may occur with GI bleeding or cancer.

Electrolyte imbalances often occur with GI illness as a result of vomiting, diarrhea, malabsorption, or use of GI suction.

Widal and blood cultur show the bacterial infection and kind of bacterial

Stool Tests Stool samples can be tested for occult blood Stool for ova (eggs) and parasites is collected

to detect intestinal infections caused by parasites and their ova

Radiographic tests

Flat Plate of the Abdomen (X-Ray)

Abdominal ultrasonography Computed Tomography

Endoscopy Esophagogastroduodenoscopy

Visualizes the esophagus (esophagoscopy), visualizes the the stomach (gastroscopy), and the duodenum duodenoscopy

Abnormalities such as inflammation, cancer, bleeding, injury, and infection can be seen

The patient to be procedure need prepared. How do nurses prepare it??

Endoscopy Anoscopy, Proctoscopy, and

sigmoidoscopy, Colonoscopy

NURSING DIAGNOSIS Imbalanced nutrition, less than body

requirements Risk for aspiration Acute pain Deficient knowledge about Anxiety Constipation Diarrhea Risk for deficient fluid volume Body image disturbance

Goal

Nursing Intervention/Nursing management