Perdarahan Saluran Cerna
Perdarahan Saluran Cerna
TERMINOLOGI
1.
2. 3.
Melena: BAB seperti, lengket campur darah tua Perdarahan terselubung: warna normal, tes kimiawi (benzidin tes) ada darah
4.
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
ETIOLOGI
Upper GI Bleed
1. 2. 3. 4. 5. 6. 7. 8. 9. Duodenal Ulcer 30 % Gastric Ulcer 20 % Varices 10 % Gastritis and duodenitis 5-10 % Esophagitis 5 % Mallory Weiss Tear 3 % GI Malignanc 1 % Dieulafoy Lesion AV Malformation-angiodysplasia
Duodenal Ulcer
Varices
Esophagitis
GI Malignancy
Esophageal Tumor
GI Malignancy
Gastric Carcinoma
Angiodysplasia
AVM
Malignancy Inflammatory Bowel Disease Ischemic Colitis Acute Infectious Colitis
10%
2-26% 10%
Radiation Colitis/Proctitis
Aortoenteric Fistula
Diverticulosis
Malignancy
Colon Carcinoma
Colonic Polyps
Hemmorrhoids
PENYEBAB
Varises esofagus Gastritis erosif Tukak peptik
Lesi Mallory-Weiss
Divertikulitis SMBA Keganasan Penyakit sistemis (hemofilia dll)
Prosedur Diagnostik
Anamnesa Penyakit hati Pedih epigastrium hubungan dg makan Alkohol, jamu, obat2 Muntah hebat, kmd muntah drh
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
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
Management of GI Bleed
Berikan Oxygen Berikan IVFD ; tree way - cairan resusitasi
Management of GI Bleed
Hubungi ICU bila ada indikasi
Periksa Vital Signs Adakah riwayat Allergies Anjurkan pasien untuk Bedrest
Tindakan Umum
1. Resusitasi: penilaian, pemantauan & menjaga kestabilan status hemodinamika
A. Tanpa Syok:
perdasarah 500 cc
observasi TD, nadi, suhu, kesadaran. Hb/ht berkala untuk transfusi
perdarahan 500-1000 cc
evaluasi kemungkinan transfusi, terpasang kristaloid (RL)
Tindakan Umum
o 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
2. Kuras Lambung
1. 2. Pipa nasogastrik Aspirasi isi lambung dengan air es 150 cc tiap 2, 4 atau 6 jam tergantung perdarahan
3.
Kuras Lambung
b. Minimal, terus-menerus.
(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,
transdermal)
*pneumonia aspirasi, laserasi s/d perforasi, obstruksi jalan nafas krn migrasi balon kedlm hipofarings
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
Nursing diagnosis
risk for Bleeding related to Active fluid volume loss hemorrhage
NURSING INTERVENTIONS
1. 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.
2. Monitor vital signs; compare with clients 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.
3. Note clients 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.
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.
6. Keep accurate record of subtotals of solutions and blood products during replacement therapy. Rationale: Potential exists for overtransfusion
7. Maintain bedrest; prevent vomiting and straining at stool. Schedule activities to provide undisturbed rest periods. Eliminate noxious stimuli.
Rationale: Activity and vomiting increases intraabdominal pressure and can predispose to further bleeding.
8. Elevate head of bed during antacid gavage. Rationale: Prevents gastric reflux and aspiration of antacids, which can cause serious pulmonary complications.
Rationale:
Increased abdominal fullness and distention, nausea or renewed vomiting, and bloody diarrhea may indicate return of bleeding.
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.