NursingassessmentinGITNor Suraizai btIbrahimPengajar JururawatU44ILKKMKubangKerianKelantannsuraizai72 1
LearningOutcome:• 1. Describethesystematicapproachtogastrointestinal assessment. • 2. Interpret gastrointestinal nsuraizai72 2
What is nursing assessment ? • Nursing assessment - komponen dalam nursing process,- merupakan kaedah sistematik yang digunakan untuk menyediakan penjagaan bagi individu, keluarga & komuniti. • Assessment ialah 1st step dalam nursing assessment dan melibatkan pengumpulan maklumat tentang status kesihatan, keperluan dan pilihan pesakit. nsuraizai72 3
Nursingassessment1. History2. Physical assessment3. Psychosocialassessmentnsuraizai72 4
Nursing assessment – history a. Patient history b. Nutrition history c. Family history d. Current history e. Bowel habit, weight loss,abdominal painhnsuraizai72 5
Patient history Past medical hx - semenjak bila - ubatan /rawatan - komplikasi sekiranya ada Past surgical hx- tahun pembedahan- lokasi pembedahan- elektif @emergency-komplikasisekiranyaadansuraizai72 6
Nutrition hx • Jadual makan • Tabiat makan mengikut jadual@tidak • Jenis pemakanan • Pedas • Berempah • Fast food • Kepercayaan pantang larang- org melayu – masakanbersantan- org cina – sup - org india - kari nsuraizai72 7
Family history Genetik / penyakit keturunan • DM /HPT / Heart problem • Cancer nsuraizai72 8
Keadaan kesihatan semasa The PQRST tool is a mnemonicusedtoassesspain and other symptoms inasystematicmanner.The acronym stands for: • Provocative/Palliative: • Quality: • Region/Radiation: • Severity: • Timing/Treatment: • This tool is commonly usedinnursingpracticetoevaluate a patient’s pain . It isavaluabletooltoaccurately describe, assess, anddocumentapatient’s pain, and aids intheselectionofappropriate pain medicationandevaluatingtheresponse to treatment . nsuraizai72 9
• P: What provokes symptoms? • sebab sebab yang menimbulkan gejala sakit samadamelakukanaktiviti @ selepas makan @ pun semasa berehat • Q - Quality and Quantity of symptoms: • Is it dull, sharp, constant, intermittent, throbbing, pulsating,aching,tearing or stabbing? • R: Radiation or Region of symptoms • Does the pain travel, or is it only in one location? Hasit alwaysbeenin the same area, or did it start somewhere else? • S: Severity of symptoms or rating on a pain scale. • Does it affect • activities of daily living such as walking, sitting, eating, orsleeping?• T: Timing/treatment it worse after • eating, changes in weather, or time of day or howlonghavetheyhadthe symptoms. nsuraizai72 10
Hx of elimination • tidak teratur/ masasentiasa berubahCorak BODiarrae/constipationnsuraizai72 11
Hx of elimination • Kandungan Najis • Tarry black colour ( Hematochezia) • bright red blood - hematocheziacomesfrom your lower GI tract. • Maleana stool • dark stools - blood associatedwithmelena comes fromyour upperGItractnsuraizai72 12
Hx of elimination • Kandungan Najis • Steatorrhea (fatty stool) • too much fat inthefeces-caused by eatingtoomanyfattyfoods or by malabsorption.• Foamy stool@frothystool • typically, diarrhea-likeandmayappear to havebubblesinit.Itmay also seemoilyor containmucus. • It can stemfromamalabsorption• disorder, pancreatitis,andother conditions. nsuraizai72 13
Nursing assessment – physical assessment • general condition• Letih • pucat • perubahan warnakulit • Jaundice • Bruishing • itching • perubahan tandavital • BP • Pulse • temp • Pain score • pemeriksaan spesifikbahagianabdomen nsuraizai72 14
pemeriksaan spesifik bahagian abdomen • inspection (4S - skin, size, symmetry and scar • 1. perubahan padawarnakulit-nodule, lesion, scarring, discoloration, inflamation,bruising, striae • Palpation • light palpation- tenderness/muscular resistance • deep palpation- kenalpasti mass nsuraizai72 15
pemeriksaan spesifik bahagianabdomenPercussion • Good hand and finger technique. Good striking and listening technique Especially important in the pulmonary and gastrointestinal systems Dull, flat, resonance, hyperresonance, or tympany sounds Percussion is an advanced technique requiring a specific skill set to perform. Auscultation• Listening to bodysoundssuchas bowel sounds, breathsounds, andheart sounds.Important inexaminationofthe heart, bloodpressure,andgastrointestinal systemListenfor bruits, murmurs, frictionrubs, and irregularitiesinpulse nsuraizai72 16
Psychosocial assessment 1. Psychology Factor 2. Social Factors 3. Health Beliefs and Practices 4. Lifestyle Factors 5. Habits and Behaviors 6. Impact on Daily Functioning 7. Educational Needs nsuraizai72 17
Psychology Factor a. Tahap stress dan Kebimbangan§ Tanya pesakit tentang tahapstressdankesan stress terhadapkesihatanpencernaan mereka. § Stress dan kebimbanganbolehmemburukkan lagi gejalagastrousus.b. Mood dan kestabilan Emosi § Menilai mood dan keadaanemosi pesakit. § Keadaan seperti kemurungankadangkala boleh nyatadengangejalagastrousus. nsuraizai72 18
Social Factors a. Support System: • Menilai rangkaian sokongan sosial pesakit, - keluarga, rakan dan komuniti. b. Family Dynamics: • Fahami hubungan dan dinamik keluarga, kerana ia boleh memberi kesan kepada keupayaan pesakit untuk mengurus kesihatan mereka dan mematuhi pelan rawatan. c. Occupation and Work Stress: • Tanya tentang pekerjaan pesakit, tekanan berkaitan kerja, dan kesan ke atas kehidupan seharian mereka, termasuk tabiat makan dan rutin. nsuraizai72 19
Health Beliefs and Practices a. Beliefs about Health and Illness: § Fahami kepercayaan dan pemahaman pesakit tentang gejala gastrousus mereka. Kepercayaan budaya dan peribadi boleh mempengaruhi tingkah laku mencari penjagaan kesihatan. b. Complementary and Alternative Therapies: § Tanya tentang sebarang terapi alternatif yang mungkin digunakan pesakit untuk menguruskan gejala GIT. nsuraizai72 20
Lifestyle Factors a. Diet and Nutrition: § Ketahui tabiat pemakananpesakit, termasukjenismakananyang diambil dandietyangdihadkan/. Tabiat pemakananyang buruk - menyumbangkepada masalahgastrousus.b. Physical Activity: § Nilai tahapaktiviti fizikalpesakit,kerana senamanyangkerapboleh memberi kesanpositifkepada kesihatanpencernaan.c. Sleep Patterns: § Tanya tentang coraktidurpesakit,kerana tidur yangtidakmencukupi atautiduryangterganggu bolehmenjejaskanfungsi gastrousus. nsuraizai72 21
Habits and Behaviors • Nilai sejarah pesakit merokokdan pengambilanalkohol, kerana ini bolehmenyumbangkepada masalahGIT. Smoking and Alcohol Use: • Tanya tentang pematuhanpesakit terhadapubat danrawatan yang ditetapkan. Medication Adherence: nsuraizai72 22
Impact onDailyFunctioninga. Functional Impairment:• Nilaikanbagaimanagejala GIT mempengaruhi kehidupanharianpesakit, termasukkerja, perhubungandan aktiviti rekreasi nsuraizai72 23
Educational Needs a. Health Literacy: § Menilai pemahaman pesakit tentang keadaan GIT dan pelan rawatan mereka. Kenal pasti bidang di mana pendidikan atau pengetahuan mungkin diperlukan nsuraizai72 24
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