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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,
http://arispurnomo.com/wp-content/uploads/2010/06/lambung.gif


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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.

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