Nursing assessment in patients with Haematemesis melena, can be done several stages, as follows
Physiological Needs Assessment
- Intake: anorexia, nausea, vomiting, weight loss.
- Elimination: constipation or diarrhea, is there melena (black blood color, thick consistency, amount)
- Urine: dark color, thick consistency
- Neuro Sensory: an impairment of consciousness (confusion, hallucinations, coma).
- Respiration: tightness, dyspnoe, hipoxia
- Activity: weakness, fatigue, lethargy, reduced muscle tone
- Consciousness, blood pressure, pulse, temperature, respiration
- Eyes: conjungtiva (there is / there is no anemis)
- Mouth: the stomach contents mixed with blood
- Extremity: pale fingertips
- Skin: Cold
- Heart: rapid or slow rhythm
- Intestine: decreased peristalsis
- Abdomen: resonant sounds, bloated or not Patellar reflex: decrease
- Diagnostic studies
- Blood tests: Hb, Ht, RBC, prothrombin, Fibrinogen, BUN, serum, ammonia, albumin.
- Examination of urine: BJ, color, thickness
- Investigations: esophagoscopy, endoscopy, ultrasound, CT Scan.
Physiological Needs Assessment
Nursing Assessments conducted include:
- The number and the color of blood hematemesis.
- The color brown: blood from the stomach may still remain, a potential aspiration.
- Sleeping position: to prevent any vomit into the airway, prevent shock.
- Signs of shock: can occur when blood counts more than 500 cc and occurs continuously.
- Number of bleeding: observation of signs of hemodynamic blood pressure, pulse, respiration, temperature. Normally blood pressure (systolic) 110 mmHg, rapid breathing, pulse 110 x / min, temperature between 38-39 degrees Celsius, cold pale skin or cyanosis of the lips, the ends of the extremities, blood circulation to the kidneys is reduced, causing the urine is reduced.
Nursing Assessment of patients with hematemesis melena related to the amount of fluid needs of the bleeding that occurred. The amount of blood, will determine the replacement fluid.
Assessment: the type of bleeding / extravasation way, to determine the location of bleeding and a ruptured blood vessel types. Bleeding that occurs suddenly, the color of fresh red blood, and continuous discharge describes bleeding that occurs in the upper gastrointestinal tract and rupture of the arteries occurs. If the emergency phase has passed, the next phase of doing an assessment of:
- Intake output balance. The assessment is done on the patient hematemesis melena caused by rupture of esophageal varices as a result of cirrochis hepatis often experience ascites and edema.
- Giving intravenous fluids on the patient.
- Urine output and record the amount per 24 hours.
- Signs of dehydration such as decreased skin turgor, sunken eyes, a small amount of urine. For patients with frequent melena hemetemesis impaired renal function.
- Ability to adapt to the diet: 3 days of liquid, then soft foods.
- Weight before bleeding
- Cleanliness of mouth: because hemetemesis and melena, the remnants of bleeding can be a source of infections that cause discomfort.
Patients with hematemesis melena in general experienced a temperature rise of about 38-39 degrees Celsius. In the pre-shock state of the skin temperature becomes cooler as a result of circulatory disturbance. Buildup of residual bleeding is the source of infection in the gastrointestinal tract so that the patient's body temperature can rise. In addition, a long infusion can also be sources of infection which causes the patient's body temperature increases.
On the patient hematemesis melena generally impaired elimination. Nursing assessment includes:
- he number and how spending due to impaired renal function. Urine is reduced and usually do care bed rest.
- Defecation, it should be noted the number, color and consistency.
- Socioeconomic background of patients, because in hematemesis melena needs to be done some actions in the enforcement of diagnosis and therapy for patients.
- Physical Needs and Psiologis
- Protection against the danger of infection. Should be studied: personal hygiene, environmental hygiene, cleanliness weaving tools, prepare and perform flushing of the stomach, how to pipe installation and maintenance of the stomach, the way of preparation and delivery of IV or IM injection.
- Protection against the danger of complications:
- Assess the endoscopy examination preparation (informed concern).
- Preparation related to taking / examination of blood.