lp hematomessis melena
TRANSCRIPT
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THEORETICAL BACKGROUND
OF
HAEMATEMESIS MELENA
IN TANJUNG WARD ( PDP ) BANJARMASIN ULIN GENERAL HOSPITAL
BY:
Hengki Hanggara
SRN
011016 D3KI
BANJARMASIN MUHAMMADIYAH HEALTH COLLEGE
INTERNASIONAL CLASS OF NURSING DIPLOMA PROGRAM
2013-2014
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ANATOMY AND PHYSIOLOGY GASTRIC
stomach in the medical language gastric, gastric digestion is one of the organs
contained in the human body. for more jelasnnya what the stomach or gastric, I will
discuss the anatomy of the stomach first. not only the anatomy of the stomach, here I
will discuss the physiology of the stomach or the complete I will discuss Stomach
Anatomy and Physiology. anatomy and physiology of the stomach which I discussed
here include: stomach lining, innervation and blood flow to the stomach, the motor
function of the stomach, the digestive function of the stomach, the secretion of gastric
function, process of food digestion in the stomach, as well as enzymes and hormones
that play a role in digestion in the stomach. tall aja yah you read below about the
anatomy of gastric physiology.
ANATOMY OF GASTRIC
Gastric located at the top of the abdomen, extending from the bottom surface of the arch to
the left until the region epigastrica costalis an umbilical. Gastric mostly located below the
bottom of the costae. Gastric roughly J-shaped and has two holes, and ostium ostium
cardiacum pyloricum, two curvatura,
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curvatura major and lesser curvature, and two walls, Paries Paries anterior and posterior.
In general, stomach is divided into 3 sections:
1. cardiac / cardiac glands found in the mouth regia heart. It only secrete mucus2. fundus / gastric located almost in the entire corpus, which this gland has three main
types of cells, namely:
Cells zigmogenik / chief cell, mesekresi pepsinogen. Pepsinogen is converted into
pepsin under acidic conditions. These glands secrete stomach lipase and renin are less
important.
parietal cells, secrete hydrochloric acid and intrinsic factor. Intrinsic factor required for
absorption of vitamin B12 in the small intestine.
mucous neck cells found in the stomach glands of the neck all. These cells
secrete mucus barrier thickness of 1 mm and protects the stomach lining against
damage by HCL or autodigesti.
3. pyloric antrum pylorus lies in regia. This Kelenajr and mucus secreting gastrin,
a peptide hormone which is influential in the process of stomach secretion.
Ingestion Food In Stomach
1. MECHANICAL
after food enters the stomach, the peristaltic movements gentle and berriak called
wave mixing (mixing wave) occurs in the stomach every 15-25 seconds. This wave of
soaking food and mix it with the secretion of stomach glands and reduce it to a watery
liquid called chyme. Some wave mixing occurs in the fundus, which is the main
storage area. The food is in the fundus for an hour or more without mixed with
gastric. During this time, digestion with saliva continue.
During digestion takes place in the stomach, more terrific wave mixing starts from the
body and is intensified when it reaches the pylorus. Pyloric spinchter almost always
there but not entirely closed. When food reaches the pylorus, each wave mixing
pressing small amounts of stomach into the duodenum through the pyloric spinchter.
Almost all the food is pressed back into the abdomen. The next wave push on and
push a little more towards the duodenum. Movement forward or back (forward /
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backward) of stomach contents is responsible for almost all the mixing that occurs in
the stomach.
2. CHEMICALPrinciples of activity in the stomach is to begin digestion of protein. For adults,
primarily through the digestive enzyme pepsin. Pepsin breaks the peptide bond
between amino acids that make up proteins. Chain protein consisting of the amino
acids are broken down into smaller fragments called peptides. Pepsin most effective
in the highly acidic environment in the stomach (pH = 2) and became inactive in
alkaline environments. Pepsin is secreted into inactive form called pepsinogen, so it
can not digest the protein in zymogenic cells that produce it. Pepsinogen is converted
into pepsin is not active until he made contact with the hydrochloric acid secreted by
the parietal cells. Second, cells are protected by mucus alkaline stomach, especially
after pepsin is activated. Mucus covering the mucosa to form a barrier between the
gastric mucus
Other enzymes of the stomach is stomach lipase. stomach lipase breaks down
triglycerides into short chain fatty molecules that are found in milk. These enzymes
operate well at pH 5-6 and has a limited role in the adult stomach. Adults are very
dependent on the enzyme that is secreted by the pancreas (pancreatic lipase) into the
small intestine to digest fat. Stomach also secrete renin which is important in
digesting milk. Renin and Ca react to milk to produce curds. Clumping prevents too
frequent passage of milk from the stomach into the duodenum to the (first part of
small intestine). Renin secretion is not present in stomach in adults.
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Enzymes and Hormones Play a Role in Digestion in Stomach
1.Gastrin hormone
Physiological significance of work
1. stimulates the secretion of acid and pepsin 1. facilitate digestion
2. stimulates the secretion of intrinsic factor 2. facilitate absorption in the intestine
3. stimulates the secretion of pancreatic enzymes 3. facilitate digestion
4. stimulates bile flow increased heart 4. facilitate digestion
5. 5 stimulates insulin secretion. facilitate glucose metabolism
6. stimulates the movement of stomach and intestines 6.mempermudah mixing
7. facilitate stomach receptive relaxation 7.lambung can easily increase the volume,
without increasing the pressure
8. increase the resting tone SEB 8. prevent reflux of stomach mixing time and
pangadukan
9. 9 inhibits gastric emptying. allows mixing the entire contents of stomach before
passing into the intestine
2. Enzyme pepsin: convert protein into peptone
3. Enzyme rennin: precipitate the casein in milk
4. Lipase: breaks down fats into fatty acids
5. HCl: mmbunuh germs and preserve food
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I.definition
Haematemesis is vomiting blood and melena are spending faeces or black feces
caused by the presence of upper gastrointestinal tract bleeding. Hematemesis color
depending on the length of contact between the blood and the size of the stomach acid
of bleeding, so it can be colored like coffee or reddish and lumpy Hematemesis
usually occurs when there is bleeding in the proximal jejunum and melena may occur
alone or together with hematemesis. At least 50-100 ml of bleeding, melena
circumstances are found. The amount of blood that comes out during hematemesis or
melena difficult to use as a benchmark to estimate the size of the upper tract bleeding
eat. Haematemesis and melena is an emergency situation and need immediate
treatment in hospital.
II.etiology
Cause of hematemesis melena:
1. Abnormalities in the esophagus
esophageal varices
Patients with hematemesis melena caused by rupture of esophageal varices, never
complained of pain or pain in epigastrum. In general, the nature of spontaneous and
massive bleeding arise. Blood spewed blackish in color and does not freeze because it
mixes with stomach acid
.
Carcinoma of the esophagus
Carcinoma of the esophagus often give complaints than hematemesis melena. Besides
complaining dysphagia, body care and anemic, just seseklai patient vomited blood,
and even then not massive. At endoscopy clear picture of carcinoma that almost
closes the esophagus and bleed easily located in the lower third of the esophagus.
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Mallory-Weiss syndrome
arising Before hematemesis preceded severe vomiting that eventually emerging
bleeding, such as in alcoholics or in early pregnancy. Usually caused by too frequent
and severe vomiting continuously. If the patient is experiencing dysphagia may be
caused by esophageal carcinoma.
Esophagitis korosiva
In a study of patients found a woman and a man vomiting blood after drinking water
hard to solder. From the analysis of the hard water found to contain citric acid and
HCl acid, which is corrosive to the oral mucosa, esophagus and stomach. Besides
vomiting blood the patient also complained of pain and burning in the mouth heat.
Chest and epigastrum.
Esophagitis and esophageal ulcers
Esophagitis when to cause more frequent bleeding is intermittem or chronic and
usually mild, so more often than hematemsis melena arise. Ulcers in the esophagus
rarely cause bleeding when compared with stomach and duodenal ulcers.
2. Abnormalities in stomach
erisova hemorrhagic gastritis
Haematemesis is not massive and arise after patients take drugs that cause stomach
irritation. Before the patient complained of vomiting heartburn. Need to be asked also
whether the patient is or frequent use rheumatic drug (NSAID + steroids) or frequently
drink alcohol or herbal remedies.
Gastric ulcer
Patients experiencing dispepsi include nausea, vomiting, heartburn hatidan before
hematemesis preceded or stinging pain in epigastrum related to food. Shortly before
arising hematemesis due to pain and pain is felt more intense. After vomiting blood
and pain reduced pain. Nature is not so massive hematemesis and melene more
dominant than hematemesis.
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Gastric Carcinoma
The incidence of gastric carcinoma in our country is classified as very rare and
generally comes to treatment already in the advanced phase, and often complain of
feeling pain, pain in the pit of the stomach often complain of feeling full quickly and
the body becomes weak. More often complain because melena.
3. Blood diseases: leukemia, DIC (disseminated intravascular coagulation),
thrombocytopenia purpura and others.
4. Other systemic diseases: uremic, and others.
5. The use of drugs that ulserogenik: class salicylates, corticosteroids, alcohol, and others.
III.pathophysiology
Bleeding from esophageal varices occurs in approximately one third of patients with liver
cirrhosis and varices. Mortality caused by first bleeding episode was 40% to 50%. This
bleeding is one of the leading causes of death in patients with liver cirrhosis. Bleeding is also
the most common complication of peptic ulcer disease and occurs in approximately 20% of
patients with ulcers.
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Patway
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SIGNS AND SYMPTOMS
1.Intestinal symptoms are not typical such as anorexia, nausea, vomiting and diarrhea.2. Fever, weight loss, quickly tired.
3. Ascites, and edemo hidratonaks.
4. Jaundice, urine sometimes become older or brownish color.
5. Hematomegali, when it has advanced liver fibrosis can small becouse. When
clinically found to be the presence of fever, jaundice and ascites, where the fever
rather than by other causes, added cirrhosis in an active state. Be careful about the
possible future prekoma and hepatic coma.
6. Vascular abnormalities such as collateral-collateral wall, koput medusa,
hemorrhoids and esophageal varices.
7. Endocrine disorder which is a sign of hiperestrogenisme namely:
- Impotence, atrosi testes, gynecomastia, loss axila and pubic hair.
- Amenorrhea, hyperpigmentation mammary areola
- Spider nevi and erythema
- Hyperpigmentation
8. finger clubbing
Diagnostic examination
1. Anamnesis, physical examination and laboratoryDo anmnesis rigorous and general condition of the patient when the weak or
decreased consciousness, it can be aloanamnesis. Past medical history needs to
be asked, such as hepatitis, chronic liver disease, alcoholism, Gastric diseases,
use of medications ulserogenik and blood diseases such as leukemia and others.
Usually the upper tract bleeding caused by eating rupture of esophageal varices
may not find any complaints of pain or pain in the epigastric region and
hematemesis symptoms occur suddenly. From the results of history is
predictable amount of bleeding out using practical TAKARA like how many
glasses, how many cans and others. Physical examination of patients with
upper tract bleeding meals that need to be considered is the general condition,
consciousness, pulse, blood pressure, anemia signs and symptoms ofhypovolemic to quickly note a more serious condition such as a rejatan or liver
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failure. Besides, look for signs of portal hypertension and cirrhosis of the liver,
such as spider naevi, ginekomasti, palmar erythema, caput Medusae, presence
of collateral, ascites, hepatosplenomegaly and leg edema. Laboratory tests such
as hemoglobin concentration, hematocrit, leukocytes, remove blood clots,
blood type and liver function tests be done on a regular basis to be able to keep
track of patients.
2. radiological examinationRadiological examinations performed with esofagogram examination for
esophageal area and continued with double contrast examination of the
stomach and duodenum. emeriksaan was conducted at various positions,
especially in the area of 1/3 distal esophagus, cardia and fundus of Gastric to
look for the presence / absence of varicose veins. To get the expected results,
the radiological examination is recommended as early as possible, and
preferably as soon as haematemesis stopped.
3. endoscopic examinationWith the various types fiberendoskop, the endoscopic examination is essential
to determine the exact place of origin and the source of bleeding. Another
advantage is the endoscopic examination can be carried out taking photos for
documentation, fluid aspiration and biopsy for examination sitopatologik. At
the upper tract bleeding dining ongoing, endoscopic examination can be done
as early as possible after the emergency or haematemesis stopped.
4. Liver ultrasonography and scanningExamination with ultrasound or liver scan can detect chronic liver disease suchas cirrhosis of the liver that may cause upper tract bleeding eat. This
examination requires specialized equipment and personnel that until now only
large city there areonly
complications:hypovolemic
shock
Anemia
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management
Treatment of patients with upper gastrointestinal tract bleeding should diraat as
early as possible and preferably in a hospital for careful monitoring and better
aid. Treatment of patients with upper tract bleeding meals include:
1. Supervision and treatment of general
Patients should be rested absolute, drugs that cause sedative effects of
morphine, meperidine and paraldehyde should be avoided.
Patients fasted for bleeding is still going on and when thebleeding stops can
be given liquid food
. infusion directly mounted and diberilan physiological saline solution for
blood is not yet available.
Monitoring of blood pressure, pulse, awareness of patients and if necessary
mounted monitor CVP.
The level of hemoglobin and hematocrit should be made to follow the state
of bleeding.
Blood transfusion is needed for menggati blood loss and maintain
hemoglobin levels of 50-70% of the normal price.
Provision of hemostatic drugs such as vitamin K, 4 x 10 mg / day,
karbasokrom (Adona AC), antacids and H2 receptor antagonist group
(cimetidine or ranitidine) is useful for tackling bleeding.
Do klisma lavemen with plain water or with the administration of antibiotics
are not absorbed by the gut, the gut sterilization tindadakan. These actions
were taken to prevent the increase in ammonia production by intestinal
bacteria, and this can lead to hepatic encephalopathy.
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2. Installation of a naso-gastric tubeNaso gastric tube fitting ends are to Gastric fluid aspiration, lavage (Gastric
kumbah) with water, and the provision of drugs. The supply of water in
Gastric will cause vasoconstriction kumbah local so expect a decrease in
gastric mucosal blood flow, thus the bleeding will stop. Kumbah Gastric will
be repeated using water as much as 100-150 ml until a clear colorless liquid
aspiration and if necessary, action can be repeated every 1-2 hours.
Endoscopic examination can be done immediately after aspiration of Gastric
fluid was clear.
3. Giving pitresin (vasopressin)Pitresin vasokoktriksi have any effect, the administration pitresin per infusion
would result kontriksi and splanchnic blood vessels thereby reducing portal
vein pressure, thus expected variceal bleeding can be stopped. Keep in mind
that pitresin can menrangsang smooth muscle of coronary vasoconstriction
that can happen, because it must be careful with the use of these drugs,
especially in patients with ischemic heart disease. Because it needs anelectrocardiogram examination and history taking to the possibility of
coronary artery disease / ischemic.
4. SB balloon Tube InstallationSB balloon tube was installed for people with variceal bleeding due to
rupture. SB tube installation should be done after the patient calm and
cooperative, so that patients can be informed and explained the meaning of
the use of these tools, how to installation and follow-up work possibilities
that could arise at the time and during installation. Some researchers get good
results with the use of the SB tube in tackling eating upper tract bleeding due
to rupture of esophageal varices. SB tube mounting complications such as
severe lacerations and rupture of the esophagus, airway obstruction were
never found.
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5. Sclerotic material usageSclerotic material morrhuate sodium by 5 ml of 5% or 3% as much sotrdecol
3 ml with the help of a flexible fiberendoskop injected varicose veins on the
surface and then pressed with SB balloon tube. This action does not require
general narcotics and can be repeated several times. This treatment has been
gaining in popularity and is one of the new treatment in tackling eating upper
tract bleeding caused by rupture of esophageal varices.
6. surgeryWhen prevention efforts fail and the above bleeding bleeding persists, then
surgery may be considered. Base surgery is performed are: ligation of
esophageal varices, esophageal transection, shortcuts porto-Kaval. Effective
operation is recommended after 6 weeks the bleeding stopped and improved
function.
Prognosis
In general, people with eating upper tract bleeding caused by rupture of
esophageal varices that have poor liver function / disturbed so that every large
and small hemorrhage resulted in severe liver failure. Many factors affect the
prognosis of patients such as age, hemoglobin level, blood pressure during
treatment, and others. The mortality rate of patients with upper tract bleeding
meals influenced by factors when treated hemoglobin, occurs / absence of
rebleeding, heart conditions, such as jaundice, encefalopati and Child class
criteria.
Given the high mortality and difficulty in tackling eating Sakuran bleeding
should be considered sections the preventive actions primarily to prevent liver
cirrhosis.
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Nursing Diagnosis (Carpenito Juall Lynda)
1. Risk of hypovolemic shock related to with hemorrhage dilambung
2. Ineffective breathing pattern related to decreased lung expansion.
3. Nutritional changes (less than requirements) related to with the inability to
process (digest) food.
4.Anxiety associated with less knowledge of disease treatment.
5. Activity intolerance related to weakness
C. intervention
1. Nursing Diagnosis. I: Risk of bleeding associated with hypovolemic shock
dilambung
outcome Not happening hypovolemic shock
Results Criteria: - Perdrahan reduced / stopped
- pulse charging regularly and strong (60-100 x / mnt)
- Decreased blood pressure (110/70 - 120/80 mmHg)
- Akral warm
Action Plan
a. TTV observations and signs of hypovolemic shock every 30 minutes
R / Early detection of changes in patient's condition so as to determine the
appropriate course of action.
b. If there are signs of hypovolemic shock give the head lower than feet ..
R / Prevent the occurrence of hypoxia
c. Observation of fluid intake and output
R / Maintaining fluid balance needs remains inadequated. Observe for bleeding
R / Early detection of changes in patient condition
e. Collaboration with the medical team in the delivery of plasma expander
R / Replacing the plasma out of blood from vomiting and bowel movements
2. II Nursing Diagnosis: Ineffective breathing pattern related to decreased lungexpansion.
outcome Shortness of breath decreases
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Results Criteria: - normal respiratory frequency (RR 16-20 x / min).
- There is no additional breath sounds.
- Kx is not hypoxic.
Action Plana. TTV observations client (especially RR).
R / tk Knowing tightness scale Kx.
b. Auscultation of breath sounds Kx.
R / Knowing whether there is an additional breath sounds.
c. Give posisiyang comfortable on Kx as semi-Fowler.
R / Reduce pain.
d. Collaboration with a team of doctors in providing drug teraepi.
R / Implement independent function.
Nursing Diagnosis. III: Changes in nutrition (lack of necessity) relating to the inability to
process (digest) food.
outcome patient needs are met
Results Criteria: - There is no abdominal tenderness
- Nausea / vomiting is reduced
- BB increased
- Appetite increased
Action Plan
a. Weigh Kx BB every day.
R / As an indicator / Kx adequate nutritional status or not.
b. HE Erikan on Kx and families about the importance of food / nutrition for themselves Kx.
R / Kx dapatkooperatif and want to eat.
c. Kx motivation to want to eat.
R / Increase appetite.
d. Collaboration with a team of dietitians in nutrition.
R / Implement independent function
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References
Smeltzer, Suzanne C. 2002.Buku Ajar Keperawatan Medikal-Bedah Brunner & Suddarth
volume 2. Jakarta: EGC.
Wilkinson, Judith M. 2007.Buku Saku Diagnosis Keperawatan. Jakarta: EGC.
.
M. Syaifoellah Noer. Prof. dr, dkk.,Ilmu Penyakit Dalam, FKUI, Jakarta, 1996.
Marlyn E. Doenges dkk,Rencana Asuhan Keperawatan, Edisi 3, EGC, Jakarta. 2000.
Lynda Juall Carpenito,Diagnosa Keperawatan, Edisi 8, EGC, Jakarta, 1999.