Pengkajian Keperawatan Gawat Darurat Lanjut 2: Abdominal and Gastrointestinal Emergencies
Pengkajian Keperawatan Gawat Darurat Lanjut 2: Abdominal and Gastrointestinal Emergencies
Pengkajian Keperawatan Gawat Darurat Lanjut 2: Abdominal and Gastrointestinal Emergencies
Keperawatan Gawat
Darurat Lanjut 2
Abdominal and
Gastrointestinal
Emergencies
National EMS Education
(Emergency Medical Services)
Standard Competencies
Medicine
Integrates assessment findings with principles
of epidemiology and pathophysiology to
formulate a field impression and implement a
comprehensive treatment/disposition plan for
a patient with a medical complaint.
National EMS Education
Standard Competencies
Abdominal and Gastrointestinal
Disorders
Anatomy, presentations, and management of
shock associated with abdominal
emergencies
− Gastrointestinal bleeding
National EMS Education
Standard Competencies
Abdominal and Gastrointestinal
Disorders
Anatomy, physiology, epidemiology,
pathophysiology, psychosocial impact,
presentations, prognosis, and management of
− Acute and chronic gastrointestinal hemorrhage
− Liver disorders
− Peritonitis
− Ulcerative diseases
− Irritable bowel syndrome
National EMS Education
Standard Competencies
Abdominal and Gastrointestinal
Disorders
Anatomy, physiology, epidemiology,
pathophysiology, psychosocial impact,
presentations, prognosis, and management of
− Inflammatory disorders
− Pancreatitis
− Bowel obstruction
− Hernias
National EMS Education
Standard Competencies
Abdominal and Gastrointestinal
Disorders
Anatomy, physiology, epidemiology,
pathophysiology, psychosocial impact,
presentations, prognosis, and management of
− Infectious diseases
− Gallbladder and biliary tract disorders
− Rectal abscesses
− Rectal foreign body obstruction
− Mesenteric ischemia
Introduction
• The number of
disorders causing
abdominal pain,
diarrhea, and
nausea is high.
− With the exception
of septicemia, most
GI disorders are
not deadly.
Introduction
• Digestion begins in
the mouth.
− The chewing
process is called
mastication.
− Enzymes in saliva
begin the chemical
breakdown of food
for absorption by
the body.
Anatomy and Physiology
• The liver:
− Produces bile, which breaks down fats
− Promotes carbohydrate metabolism
− Detoxifies drugs
− Completes the breakdown of dead blood cells
− Stores vitamins and minerals
Anatomy and Physiology
• Colon (large
intestine)
− Moves undigested
food (feces) to be
eliminated from the
body
Anatomy and Physiology
• Ensure safety.
• Look for MOI (mecanisme of injury) or NOI
Nature of illness).
• Take standard precautions.
• Always have equipment for hygiene.
Primary Assessment
• Circulation
− Assess skin color, temperature, and moisture.
− Determine pulse rate.
− Ensure blood pressure reading is accurate.
− Take note of amount of blood.
Primary Assessment
• Transport decision
− Based on primary assessment
− If positive orthostatic vital signs, carefully
consider how to move the patient.
− Choose the mode of ambulance.
History Taking
• Detailed abdominal
examination
− Keep the muscles
from flexing.
− Check for skin
irregularities.
• Scars
© Medical-on-Line Alamy Images
• Striae
Secondary Assessment
• Protuberance may
be caused by:
− Excessive weight
gain
− Ascites
• Auscultate for
bowel sounds.
Secondary Assessment
• Palpate the
abdomen.
− Begin farthest
away from the
pain.
− Indent the
abdomen wall
about 2″ to 4″.
− Assess for
discomfort, rigidity,
and masses.
Secondary Assessment
• Pathophysiology
− Caused by pressure increases in blood vessels
surrounding the esophagus and stomach
− Blood cannot easily flow through damaged liver.
• Blood backs up into the portal vessels.
Upper Gastrointestinal Bleeding:
Esophagogastric Varices
• Management
− General management guidelines
• Accurate assessment of blood loss
− In-hospital treatment includes:
• Stopping the bleeding
• Aggressive fluid resuscitation
• Possible endoscopy
Upper Gastrointestinal Bleeding:
Mallory-Weiss Syndrome
• Pathophysiology
− Junction between the esophagus and the
stomach tears
• Generally due to severe vomiting
Upper Gastrointestinal Bleeding:
Mallory-Weiss Syndrome
• Assessment
− Bleeding may be light to severe.
− In extreme cases, patients will have:
• Signs and symptoms of shock
• Epigastric abdominal pain
• Hematemesis
• Melena
Upper Gastrointestinal Bleeding:
Mallory-Weiss Syndrome
• Management
− Aimed at determining the extent of blood loss
− In-hospital management may include:
• Volume resuscitation
• Endoscopy
• Attempt to repair the tear
Upper Gastrointestinal Bleeding:
Peptic Ulcer Disease (PUD)
• Pathophysiology
− Erosion of the mucous that lines the stomach
and duodenum
− Typically occurs over weeks, months, or years
− Variety of causes
• Infection with Helicobacter pylori
• Erosive gastritis
Upper Gastrointestinal Bleeding:
Peptic Ulcer Disease (PUD)
• Assessment
− Burning or gnawing pain in the stomach
• Disappears after eating, but returns hours later
− Other common symptoms may include:
• Vomiting
• Belching
• Heartburn
Upper Gastrointestinal Bleeding:
Peptic Ulcer Disease (PUD)
• Management
− Assess blood loss and manage hypotension.
− Monitor orthostatic vital signs.
− In-hospital management includes:
• Acid neutralization
• Reduction therapies
• Endoscopy if needed
Upper Gastrointestinal Bleeding:
Gastroesophageal Reflux Disease
• Pathophysiology
− Sphincter between the esophagus and stomach
opens, allowing stomach acids to travel up
− Can cause a burning sensation within the chest
− Over time it can cause damage to the
esophageal wall and possible bleeding.
Upper Gastrointestinal Bleeding:
Gastroesophageal Reflux Disease
• Assessment
− Signs and symptoms
• Heartburn
• Coughing or difficulty swallowing
• Bleeding, resulting in hematemesis and melena
Upper Gastrointestinal Bleeding:
Gastroesophageal Reflux Disease
• Management
− Treatment focuses on decreasing acidity.
• Antacids, proton pump inhibitors, H2 blockers
− Symptoms can be confused with myocardial
infarction.
Lower Gastrointestinal
Bleeding: Hemorrhoids
• Pathophysiology
− Swelling and inflammation of blood vessels
around the rectum
− Caused by increased rectal pressure or irritation
Lower Gastrointestinal
Bleeding: Hemorrhoids
• Assessment
− Signs and symptoms:
• Hematochezia
• Rectal itching
• Small mass on rectum
Lower Gastrointestinal
Bleeding: Hemorrhoids
• Management
− Prehospital management is supportive.
− Obtain orthostatic vital signs.
− In-hospital management may include creams.
− Prevention includes eating a high-fiber diet.
Lower Gastrointestinal
Bleeding: Anal Fissures
• Pathophysiology
− Linear tears in the
mucosal lining
near and in the
anus
Lower Gastrointestinal
Bleeding: Anal Fissures
• Assessment
− Painful defecation
• Management
− Place dressing over anus.
− Do NOT pack fissure or anus.
Acute Inflammatory Conditions
• Management
− Pain medications: meperidine and morphine
− Medication for nausea is often necessary.
Appendicitis
• Pathophysiology
− Fecal and other matter builds up in appendix.
− Build-up of pressure will eventually cause the
organ to rupture, resulting in:
• Peritonitis
• Sepsis
• Death
Appendicitis
• Assessment
− Stages of presentation
• Early—periumbilical pain, nausea, vomiting
• Ripe—pain in lower right quadrant
• Rupture—decrease in pain (decrease in pressure)
− Evaluate for peritonitis with Dunphy sign.
Appendicitis
• Management
− Assess for septicemia.
− Volume resuscitation
• Use dopamine if crystalloids are not effective.
− Administer pain and antinausea medications.
Diverticulitis
• Pathophysiology
− Diverticulum: weak area in the colon that begins
to have pockets (diverticula)
− Diverticulosis: condition of having diverticula
− Diverticulitis: Inflammation of diverticuli
Diverticulitis
• Pathophysiology
− A diet low in fiber creates more solid stool.
− If feces gets trapped in diverticula, inflammation
and infection occur and may cause:
• Scarring
• Adhesions
• Fistula
Diverticulitis
• Assessment
− Signs and symptoms include:
• Abdominal pain, usually localized on the left lower
abdomen
• Classic infection signs
• Constipation or diarrhea
Diverticulitis
• Management
− Ensure severe infection is not present.
− Patients may need fluids and/or dopamine.
− In-hospital treatment includes:
• Antibiotics
• Liquid diet
• Surgery
Pancreatitis
• Pathophysiology
− Inflammation of the pancreas
− Occurs when the tube carrying enzymes
becomes blocked, leading to autodigestion
− Can occur suddenly or over many months
− May be single or episodic attacks
Pancreatitis
• Assessment
− Signs and symptoms may include:
• Sharp pain in the epigastric area or right upper
abdomen
• Pain radiating to the back
• Muscle spasms
Pancreatitis
• Management
− Directed by general management guidelines
− Assess for signs of severe hemorrhage.
− Meperidine is the choice for pain management.
Ulcerative Colitis
• Pathophysiology
− Generalized inflammation of the colon
− Causes a thinning of the intestinal wall and a
weakened rectum
− Peaks between ages 15 and 25 years and 55
and 65 years
Ulcerative Colitis
• Assessment
− Signs and symptoms may include:
• Gradual onset of bloody diarrhea
• Hematochezia
• Mild to severe abdominal pain
• Skin lesions
Ulcerative Colitis
• Management
− Determine the degree of hemodynamic
instability.
− Administer fluids, if necessary.
− Follow the general management guideline.
Irritable Bowel Syndrome (IBS)
• Pathophysiology
− Patients often show:
• Hypersensitivity of bowel pain receptors
• Hyperresponsiveness of the smooth muscle
• Psychiatric disorder connection
Irritable Bowel Syndrome (IBS)
• Pathophysiology (cont’d)
− Hyperresponsiveness can cause spasm.
• Can cause constipation and bloating or diarrhea
− Typically begins during childhood
− Can be triggered by various stimuli
Irritable Bowel Syndrome (IBS)
• Assessment
− You will typically be called when the patient is
having a flare-up of symptoms.
• Management
− Mainly supportive
− Assessment should include the patient’s mood.
Crohn Disease
• Pathophysiology
− Involves the entire GI tract
− A series of attacks leaves a scarred, narrowed,
and weakened portion of the small intestine.
• Can cause bowel obstruction
Crohn Disease
• Assessment
− Signs and symptoms may include:
• Rectal bleeding
• Weight loss
• Skin disorders
Crohn Disease
• Management
− Prehospital care should focus on general
management guidelines, including:
• Volume resuscitation
• Control of nausea and pain
Acute Infectious Conditions
• Pathophysiology
− Conditions
involving infection
with fever,
abdominal pain,
diarrhea, nausea,
and vomiting
− Can be caused by
various organisms
• Typically enter via
the fecal-oral route
Acute Gastroenteritis
• Assessment
− Symptoms may show anywhere from several
hours to several days from contact
− Can last two or three days, or several weeks
Acute Gastroenteritis
• Assessment (cont’d)
− Signs and symptoms may include:
• Diarrhea of various types
• Nausea and vomiting
• Anorexia
− Assess for dehydration, hemodynamic
instability, and electrolyte imbalance.
Acute Gastroenteritis
• Management
− Determine the degree of fluid deficit.
− Obtain orthostatic vital signs.
− Analgesic and antiemetic medications
− Teach patients about safe food and water use.
Rectal Abscess
• Pathophysiology
− Caused when the ducts carrying mucus to the
rectal area become blocked
• Allows bacteria to grow and spread to the anus
Rectal Abscess
• Assessment
− Symptoms may include:
• Rectal pain that increases with defecation
• Rectal drainage
• Constipation
• Management
− Focus on keeping the patient comfortable.
Liver Disease: Cirrhosis
• Pathophysiology
− Early liver failure, which may be hallmarked by:
• Portal hypertension
• Deficiencies with coagulation
• Diminished detoxification
Liver Disease: Cirrhosis
• Assessment
− First stage may include:
• Weakness and fatigue
• Nausea and vomiting
• Anorexia
• Pruritus
Liver Disease: Cirrhosis
• Assessment
(cont’d)
− 2nd stage may
include:
• Alcoholic stools
• Dark urine
• Icteric conjunctiva Courtesy of Dr. Thomas F. Sellers/Emory University/CDC
• Ascites
• Enlarged liver
Liver Disease: Cirrhosis
• Assessment (cont’d)
− Common blood tests:
• Aminotransferases
• Alkaline phosphatase
• Albumin
• Bilirubin
Liver Disease: Cirrhosis
• Management
− Prehospital care should be supportive.
− Involves bleeding control and medication
− Use lower ends of medication dose range.
Liver Disease: Hepatic
Encephalopathy
• Pathophysiology
− Brain impairment due to diminished liver
function
− Underlying causes:
• Increased levels of ammonia
• Diminished cellular energy supplies
• Change in blood-brain barrier permeability
Liver Disease: Hepatic
Encephalopathy
• Assessment
− Can range from mild memory loss to coma
− May be precipitated by:
• Infection
• Renal failure
• GI bleeding
• Constipation
Liver Disease: Hepatic
Encephalopathy
• Management
− Mainly supportive
− Ensure that LOC status is not from other cause.
• Check blood glucose levels.
• Assess for trauma and overdose.
• Take a medical history.
Obstructive Conditions
• Pathophysiology
− Most often caused by post-operative adhesions
− Other causes include:
• Cancer
• Crohn disease
• Hernias
• Foreign bodies
Small-Bowel Obstruction
• Assessment
− Signs and symptoms may include:
• Crampy and intermittent abdominal pain
• Initial diarrhea, nausea, and vomiting
• Increased pressure
• Constipation
Small-Bowel Obstruction
• Management
− Monitor blood pressure, and perform volume
resuscitation.
− Administer dopamine as needed.
− Consider using a nasogastric tube.
− Antiemetics are indicated.
Large-Bowel Obstruction
• Pathophysiology
− Caused by either mechanical obstruction or
colon dilation
− Imaging studies determine the location and
extent of obstruction.
• Once located, can be easily treated
Large-Bowel Obstruction
• Assessment
− Signs and symptoms may include:
• Nausea and vomiting
• Distended abdomen
• Absent bowel sounds
• Peritonitis signs if bowel has ruptured
Large-Bowel Obstruction
• Management
− Same as for small bowel obstruction
Hernia
• Pathophysiology
− Organ/structure protrusion into adjacent cavity
− To check for an inguinal hernia:
• Place fingers on lower abdomen.
• Instruct patient to cough.
• Weakness in abdominal wall will present as bulging.
Hernia
• Pathophysiology (cont’d)
− Caused by any condition that causes intra-
abdominal pressure:
• Obesity
• Standing for long periods
• Straining during bowel movements
• Chronic obstructive pulmonary disease
Hernia
• Assessment
− Four types
• Reducible
• Incarcerated
• Strangulated
• Incisional
Hernia
• Management
− Focus on supportive measures.
− Pain management
− Assess for sepsis
Rectal Foreign Body
Obstruction
• Pathophysiology
− Originates from upper GI tract or anal insertion
• Assessment
− Presents with sudden rectal pain with
defecation
− Determine if the rectum has been perforated.
Rectal Foreign Body
Obstruction
• Management
− Do NOT attempt to remove object.
− Prehospital management should be limited to
patient comfort.
• Treat with analgesia if indicated.
• Closely monitor vital signs.
Mesenteric Ischemia
• Pathophysiology
− Interruption of the blood supply to the
mesentery
− Can be caused by:
• Arterial embolism
• Thrombosis
• Profound vasospasm
Mesenteric Ischemia
• Assessment
− Gradual or sudden onset
− Symptoms include:
• Severe pain with ill-defined location
• Nausea, vomiting, and diarrhea
• Possible blood in stool
Mesenteric Ischemia
• Management
− Patients require rapid transportation.
− Monitor closely.
− Check vitals for signs of sepsis.
− Fluid resuscitation in cases of shock
− Give analgesics as needed.
Gastrointestinal Conditions in
Pediatric Patients
• GI complaints are common in children.
− Prolonged vomiting, diarrhea, or bleeding can
lead to severe changes in sodium and
potassium levels.
Gastrointestinal Conditions in
Pediatric Patients
• Congenital GI
anomalies
− Gastrochisis:
portions of the GI
system lie outside
the abdominal wall
• GI bleeding can
occur in children.
Gastrointestinal Conditions in
Pediatric Patients
• Careful assessment is critical.
− Check skin turgor, pulse rate, and peripheral
pulse status.
− Severe fluid loss may cause diminished LOC.
• Standard fluid resuscitation: 20 mL/kg isotonic fluid
− Get a detailed medical history from the parent.
Gastrointestinal Conditions in
Pediatric Patients
• Patients may have a gastrostomy tube.
− If dislodged, place a sterile dressing over it.
− If clogged, talk about ways to clear the tube.
− If the blockage cannot be easily managed, turn
off the feeding, clamp the tube, and transport.
Gastrointestinal Conditions in
Older Adults
• GI diseases more prevalent in older adults
• Abdominal pain can also be a symptom of a
cardiac condition.
− Obtain a thorough history and physical exam.
− Consider a 12-lead ECG.
− Monitor vital signs.
Prevention Strategies
• Many behaviors
can prevent or limit
severity of GI
diseases.
Prevention Strategies
Summary