PERDARAHAN SALURAN CERNA.ppt
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Transcript of PERDARAHAN SALURAN CERNA.ppt
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PERDARAHAN SALURAN CERNA
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TERMINOLOGI
1. Hematemesis: muntah darah, merah
kehitaman, endapan bubuk air kopi
2. Melena: BAB seperti, lengket campur darah tua
3. Perdarahan terselubung: warna normal, tes
kimiawi (benzidin tes) ada darah
4. Hematochezia : darah segar melalui rektum
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Perdarahan Saluran Makan Bagian Atas
“adalah perdarahan pd saluran makan proksimal dari ligamentum Treitz”
• Perdarahan Saluran Makan Bagian Atas
“adalah perdarahan pd saluran makan proksimal dari ligamentum Treitz”
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ETIOLOGI
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Upper GI Bleed1. Duodenal Ulcer 30 %2. Gastric Ulcer 20 %3. Varices 10 %4. Gastritis and duodenitis 5-10 %5. Esophagitis 5 %6. Mallory Weiss Tear 3 %7. GI Malignanc 1 %8. Dieulafoy Lesion9. AV Malformation-angiodysplasia
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Duodenal Ulcer
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Varices
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Esophagitis
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GI Malignancy
• Esophageal Tumor
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GI Malignancy
• Gastric Carcinoma
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Angiodysplasia
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Waspadai Lower GI Bleed
1. Hematochezia2. Blood in Toilet3. Clear NGT aspirate4. Normal Renal Function5. Usually Hemodynamically stable
Only 1/3 pasien mempunyai hasil (+) orthostatics (tilt test).
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Etiology of Lower GI Bleed
Diverticular 20%AVM 10%Malignancy 2-26%Inflammatory Bowel Disease 10%Ischemic ColitisAcute Infectious ColitisRadiation Colitis/ProctitisAortoenteric Fistula
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Diverticulosis
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Malignancy
• Colon Carcinoma
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Colonic Polyps
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Hemmorrhoids
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PENYEBAB
• Varises esofagus• Gastritis erosif• Tukak peptik• Lesi Mallory-Weiss • Divertikulitis SMBA• Keganasan• Penyakit sistemis (hemofilia dll)
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Prosedur Diagnostik
Anamnesa• Penyakit hati• Pedih epigastrium hubungan dg makan• Alkohol, jamu, obat2• Muntah hebat, kmd muntah drh
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Pemeriksaan fisik
• Status hemodinamik : HR, BP, tilt test, RR, O2 saturation
• General appearance, Mental status• Vena jugularis (Neck veins), oral mucosa• Skin temperature and color• Pemeriksaan Abdominal • Pemeriksaan Rectal• Stigma of Cirrhosis• NG Tube findings• Urine output
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Pemeriksaan Laboratorium
1. Hematologi: Hb, ht, lekosit, eritrosit, trombosit, morfologi darah tepi, gol.drh, faal pembekuan
2. Biokimia darah: faal hati, faal ginjal, gula drh
3. Urin rutin
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Management of GI Bleed
• Berikan Oxygen• Berikan IVFD ; tree way
- cairan resusitasi - persiapan transfusi darah.
• Jaga patensi jalan napas (Airway Protection)
• Kaji secara kontinyu gangguan mental dan resiko aspirasi terutama pada pasien dengan perdasarahan massive
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Management of GI Bleed
Hubungi ICU bila ada indikasi - perdarahan yang signifikan dg ketidakstabilan hemodynamic
Transfusion- harus berdasarkan status hemodinamik- Cardiopulmonary symptoms-cardiac ischemia or shortness of
breath, decreased pulse oxymetri- 1 unit PRBC increases Hgb by 1 mg/dL and increase Hct by 3 %- FFP for INR greater than 1.5- Platelets for platelet count less than 50K
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• Periksa Vital Signs• Adakah riwayat Allergies• Anjurkan pasien untuk Bedrest• Pasang Foley cateter• Diet: NPO
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Tindakan Umum1. Resusitasi: penilaian, pemantauan & menjaga
kestabilan status hemodinamika
A. Tanpa Syok: o perdasarah 500 cc
observasi TD, nadi, suhu, kesadaran. Hb/ht berkala untuk transfusi
o perdarahan 500-1000 ccevaluasi kemungkinan transfusi, terpasang kristaloid (RL)
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Tindakan Umumo Perdarahan masif >1000 cc
Hb < 8 gr % infus kristaloid dipercepat, menunggu transfusi, pantau tekanan vena sentral.
a) Telentang tanpa bantal, kepala miring kesamping, O2 via kateter hidung 5 l/menit, kateter foley
b) RL 1000 cc dlm 1 jamc) Tetap syok, infus plasma ekpander sambil tunggu
darah, jumlah transfusi tergantung respon hemodinamik: CVP stabil normal, vital baik, diuresis cukup, ht > 30%
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2. Kuras Lambung
1. Pipa nasogastrik2. Aspirasi isi lambung dengan air es 150 cc tiap 2, 4
atau 6 jam tergantung perdarahan3. Air kurasan merah/keruh: masih terjadi, nilai sifat
& macamnya: a. Minimal, terus-menerus, >70 th EKG
abnormal : teruskan kuras dg air es + nor-adrenalin 2 amp/150 cc air es
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Kuras Lambung
b. Minimal, terus-menerus. - < 70 th EKG normal: infus vasopresin 0,2 (octapressin,
glypressin) unit/mnt (10 amp @ 10 unit larutkan dlm 500 cc D5 % 20 gtt/m/8 jam), bisa diulang 2 x lagi, bila drh berkurang/stop, teruskan dosis 0,1 unit/m
- EKG abn: vasopresin + nitrogliserin (iv, sub lingual atau transdermal)
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Sengstaken-Blakemore tube (SB tube)
c. Masif, usia >70 th EKG abnormal, diduga varises esofagus, farmakologis gagal ----- tamponade
SB tube.
*pneumonia aspirasi, laserasi s/d perforasi, obstruksi
jalan nafas krn migrasi balon kedlm hipofarings
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Penilaian tindakan terapi
Penilaian tindakan terapi berdasar:- Penilaian perdarahan akut gawat, bila utk
mempertahankan hemodinamika yg stabil (Hb > 8 gr% & Ht > 30%) perlu transfusi darah 3 unit dalam waktu:
+ 8 jam : perdarahan akut gawat tk.I +24 jam : sda tk.II +48 jam : sda tk.III- Menentukan kapan terapi gagal/berhasil
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Nursing diagnosis
• risk for Bleeding related to Active fluid volume loss—hemorrhage
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NURSING INTERVENTIONS1. Note color and characteristics of vomitus, nasogastric
(NG) tube drainage, and stools.
• Rationale: The first step in managing bleeding is to determine its location. Bright red blood that does not clear signals recent or acute arterial bleeding, perhaps caused by gastric ulceration; dark red blood may be old blood that has been retained in intestine or venous bleeding from varices. Coffee-ground appearance is suggestive of partially digested blood from slowly oozing area. Undigested food indicates obstruction or gastric tumor. In a rapid upper GI bleed, stool color may be red or maroon because of rapid transit time through the GI tract.
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2. Monitor vital signs; compare with client’s normal and previous readings. Take blood pressure (BP) in lying, sitting, and standing positions when possible.
Rationale: Changes in BP and pulse may be used for rough estimate of blood loss; BP less than 90 mm Hg and pulse greater than 110 suggest a 25% decrease in volume, or approximately 1,000 mL. Postural hypotension reflects a decrease in circulating volume.
Note: Heart rate may not rise above normal until up to 30% of total blood volume is lost.
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3. Note client’s individual physiological response to bleeding, such as changes in mentation, weakness, restlessness, anxiety, pallor, diaphoresis, tachypnea, and temperature elevation.
• Rationale: Symptomatology is useful in gauging severity and length of bleeding episode. Worsening of symptoms may reflect continued bleeding, inadequate fluid replacement, and shock.
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4. Measure central venous pressure (CVP) if available.
• Rationale: Reflects circulating volume and cardiac response to bleeding and fluid replacement. CVP values between 5 and 20 cm H2O usually reflect adequate volume.
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5. Monitor intake and output (I&O) and correlate with weight changes. Measure blood and fluid losses via emesis, gastric suction or lavage, and stools.
• Rationale: Provides guidelines for fluid replacement.
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6. Keep accurate record of subtotals of solutions and blood products during replacement therapy.
• Rationale: Potential exists for overtransfusion of fluids, especially when volume expanders are given before blood transfusions.
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7. Maintain bedrest; prevent vomiting and straining at stool. Schedule activities to provide undisturbed rest periods. Eliminate noxious stimuli.
Rationale: Activity and vomiting increases intra-abdominal pressure and can predispose to further bleeding.
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8. Elevate head of bed during antacid gavage.
• Rationale: Prevents gastric reflux and aspiration of antacids, which can cause serious pulmonary complications.
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9. Note signs of renewed bleeding after cessation of initial bleed.
• Rationale: Increased abdominal fullness and distention, nausea or renewed vomiting, and bloody diarrhea may indicate return of bleeding.
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10. Observe for secondary bleeding from nose or gums, oozing from puncture sites, or appearance of ecchymotic areas following minimal trauma
• Rationale: Loss of or inadequate replacement of clotting factors may precipitate development of DIC.