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 Objective Data
 Health History  Physical assessment
 Medications  Diagnostic Tests
 Nutritional Assessment  Laboratory tests
 Family History  Radiographic tests
 Cultural Influences  Endoscopy
 Gastric analysis
 Cytological studies
 Magnetic resonance
imaging
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