Pencernaan_pengkajian

43
NURSING CARE of patients With Gastroiintestinal System Disorder

Transcript of Pencernaan_pengkajian

Page 1: Pencernaan_pengkajian

NURSING CARE of patients With Gastroiintestinal System Disorder

Page 2: Pencernaan_pengkajian
Page 3: Pencernaan_pengkajian

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.

Page 4: Pencernaan_pengkajian

QUESTIONS

Page 5: Pencernaan_pengkajian

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?

Page 6: Pencernaan_pengkajian

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

Page 7: Pencernaan_pengkajian

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

Page 8: Pencernaan_pengkajian

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,.

Page 9: Pencernaan_pengkajian

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

Page 10: Pencernaan_pengkajian

You Will Become the good Nurses

Page 11: Pencernaan_pengkajian

NURSING ASSESSMENT AND DIAGNOSIS Gastroiintestiinal System

Page 12: Pencernaan_pengkajian

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

Page 13: Pencernaan_pengkajian

SUBJECTIVE DATA

Page 14: Pencernaan_pengkajian

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

Page 15: Pencernaan_pengkajian

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

Page 16: Pencernaan_pengkajian

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.

Page 17: Pencernaan_pengkajian
Page 18: Pencernaan_pengkajian

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

Page 19: Pencernaan_pengkajian

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.

Page 20: Pencernaan_pengkajian

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.

Page 21: Pencernaan_pengkajian

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

Page 22: Pencernaan_pengkajian

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???

Page 23: Pencernaan_pengkajian

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,.

Page 24: Pencernaan_pengkajian

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

Page 25: Pencernaan_pengkajian

Nutritional Assessment A diet history should include :

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

supplements

Page 26: Pencernaan_pengkajian

Family History Some GI problems such as colon

cancer are thought to be hereditary

Page 27: Pencernaan_pengkajian

OBJECTIVE DATA

Page 28: Pencernaan_pengkajian

Objective Data Physical assessment Diagnostic Tests

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

Page 29: Pencernaan_pengkajian

PHYSICAL ASSESSMENT(REVIEW GI SYSTEM)

General appearance Skin Head Abdomen Psychological factor

Page 30: Pencernaan_pengkajian

General appearance Aktivitas Motorik Posisi tubuh Perubahan status nutrisi : Berat

Badan dan Penampilan status kesehatan

Page 31: Pencernaan_pengkajian

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

Page 32: Pencernaan_pengkajian

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

Page 33: Pencernaan_pengkajian

Abdomen

Page 34: Pencernaan_pengkajian
Page 35: Pencernaan_pengkajian

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

Page 36: Pencernaan_pengkajian

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

Page 37: Pencernaan_pengkajian

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

Page 38: Pencernaan_pengkajian

Radiographic tests

Flat Plate of the Abdomen (X-Ray)

Abdominal ultrasonography Computed Tomography

Page 39: Pencernaan_pengkajian

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??

Page 40: Pencernaan_pengkajian

Endoscopy Anoscopy, Proctoscopy, and

sigmoidoscopy, Colonoscopy

Page 41: Pencernaan_pengkajian

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

Page 42: Pencernaan_pengkajian

Goal

Page 43: Pencernaan_pengkajian

Nursing Intervention/Nursing management