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Makalah Askep Endoskopi Kurang Daftar Isi Sama Cover
Makalah Askep Endoskopi Kurang Daftar Isi Sama Cover
Patien Particular
Case Scenario
Patien come to hospital with stomach pain after food and discomfort gastric (Duration
rectal sternal discomfort), feel vomiting and ask for condition check. Patient was
complaining of vomiting for 6 episode in a day. Patien complain that hunger feeling
increase more then before so that his weight is up.
Patien vital sign were taken as table below
After checking vital sign, the patient tell about his medical history. Patient was being
seen by doctor in the ward and able to proceed for OGDS (oesopaghus
Doedenouscopy) as planed. For a while, patient suspected GERD indication, so that
the patient will be processed in OGDS.
Allergy :
N/A
Present Medication :
Anti Depression
Structure
The stomach is part of the digestive system and is connected to the:
esophagus – a tube-like organ that connects the mouth and throat to the
stomach. The area where the esophagus joins the stomach is called the
gastroesophageal (GE) junction.
small intestine (small bowel) – a long tube-like organ that extends from the
stomach to the colon (large intestine or large bowel). The first part of the small
intestine is called the duodenum, and it is this part that is connected to the
stomach.
The stomach is surrounded by a large number of lymph nodes.
Regions of the stomach
The stomach is divided into 5 regions:
The cardia is the first part of the stomach below the esophagus. It contains the
cardiac sphincter, which is a thin ring of muscle that helps to prevent stomach
contents from going back up into the esophagus.
The fundus is the rounded area that lies to the left of the cardia and below
the diaphragm.
The body is the largest and main part of the stomach. This is where food is
mixed and starts to break down.
The antrum is the lower part of the stomach. The antrum holds the broken-
down food until it is ready to be released into the small intestine. It is
sometimes called the pyloric antrum.
The pylorus is the part of the stomach that connects to the small intestine. This
region includes the pyloric sphincter, which is a thick ring of muscle that acts
as a valve to control the emptying of stomach contents (chyme) into the
duodenum (first part of the small intestine). The pyloric sphincter also prevents
the contents of the duodenum from going back into the stomach.
a. anamnesis
1) Main complaint
In anamnesis main complaint is a complaint commonly found
associated with the condition of gastroesophageal reflux and
gastric acid contacts the esophageal mucosa are on complaints
of chest pain (retrosternal).
2) History of present illness
In hiatal hernia usually existing complaints such as heartburn
(taste very uncomfortable when food started to go after
ingestion), regurgitation (backflow of stomach contents into
the esophagus), vomiting complaint taste sour, bitter or
unpalatable in the oral cavity, increased frequency burp, often
choking, chest feel like pressure, discomfort in the abdomen,
upper abdominal tenderness, especially after eating, sudden
cough and difficulty swallowing.
3) Past medical history
Past medical history is important to be studied is a systemic
disease, such as diabetes mellitus, hypertension, tuberculosis
is considered as a means of preoperative assessment.
4) psychosocial
In the psychosocial assessment will get increased anxiety
because of chest pain (retrosternal) and plan the surgery and
the need for compliance with preoperative information.
b. Physical examination
In a general survey of patients with hiatal hernia patient looks weak
and in pain, TTV changes secondary to pain, weight loss in patients
with symptoms of dysphagia is chronic.
According to Erickson (2009), diagnostic assessments that can help,
including the examination of tissue culture to detect tuberculosis
adenitis, plain abdominal to detect the presence of air in the intestine
and to detect the presence of ileus, and ultrasound to assess the mass
of hiatal hernia.
c. endoscopic Procedures
1. Radiographic assessment
While performing contrast barium studies of the upper
gastrointestinal tract, a globular structure termed "phrenic ampulla"
is seen above the diaphragm during swallows.32 This structure has
traditionally been Considered to be a physiologic finding, but the
study using simultaneous fluoroscopy and manometry demonstrated
that it corresponded to a small hiatal reducing hernia.16 There are
Several landmarks of the phrenic ampulla that are worth
mentioning. The upper margin of the phrenic ampulla abuts the
tubular esophagus forming a structure called the "A" ring, the which
is a muscular ring. This ring corresponds to the upper margin of the
LES. The lower margin of the phrenic ampulla is demarcated by the
diaphragmatic indentation. Within the phrenic ampulla, a mucosal
ring ( "B" ring) can be identified, the which corresponds to the
squamocolumnar junction (Zline) or the union of the esophagus
with the stomach.34 When the "B" ring is prominent, ie, the luminal
diameter of 2 cm (Fig. 1) .30,33,34 The limitation of this method is
that it is not always possible to detect all the landmarks of the
phrenic ampulla. Defining hiatal hernia Becomes especially
problematic when the "B" ring, marker Necessary for defining the
presence of a hiatal hernia that is only detectable in about 15% of
subjects, can not be identified. In the absence of the "B" ring, the
result of barium contrast studies to diagnose a hiatal hernia can
Become quite inconsistent. In this case, the upper margin of the
Rugal Folds is used instead as the reference point. In addition, the
timing of taking images can serve as a source of inaccuracy, since
the distance between the "B" ring and the diaphragmatic indentation
would vary Depending on the point of swallowing at the which the
images were taken. The lack of standardized protocols as to
Whether examination should be done in an upright or supine
position etc. Also adds to the inconsistencies in diagnosing hiatal
hernias. Furthermore, in order to observe your the relationship
between the aforementioned structures and view them under
fluoroscopy, the patient should swallow the contrast material. Since
swallowing itself distends and shortens the esophageal lumen,
diagnosing hiatal hernia <2 cm Becomes impractical with barium
contrast studies. Also adds to the inconsistencies in diagnosing
hiatal hernias. Furthermore, in order to observe your the relationship
between the aforementioned structures and view them under
fluoroscopy, the patient should swallow the contrast material. Since
swallowing itself distends and shortens the esophageal lumen,
diagnosing hiatal hernia <2 cm Becomes impractical with barium
contrast studies. Also adds to the inconsistencies in diagnosing
hiatal hernias. Furthermore, in order to observe your the relationship
between the aforementioned structures and view them under
fluoroscopy, the patient should swallow the contrast material. Since
swallowing itself distends and shortens the esophageal lumen,
diagnosing hiatal hernia <2 cm Becomes impractical with barium
contrast studies.
2. Endoscopical assessment
The use of endoscopy has Become widespread over the past few
Decades and is now Considered the standard modality for
diagnosing and treating diseases of the upper gastrointestinal tract.
Although barium contrast study has been the most commonly
applied method for diagnosing worldwide hiatal hernia, hiatal
hernia is Increasingly Diagnosed with endoscopy (Fig. 1). The most
commonly accepted diagnostic criterion of endoscopic hiatal hernia
is the proximal dislocation of GEJ of> 2 cm above the
diaphragmatic indentation. However, controversy still exists as to
the which the marker of GEJ should serve as the reference to
diagnose the presence of a hiatal hernia: SCJ, the upper margin of
the gastric folds or the distal margin of the palisade zone. Therefore,
to diagnose hiatal hernia endoscopically, endoscopic definition of
GEJ should first be clarified. SCJ is the circumferential margin that
is formed by the pinkish gray colored squamous epithelium of the
esophagus and the reddish orange colored columnar epithelium of
the stomach. This transition zone IS ALSO called the "Z-line" and
can vary in contour.35 SCJ usually corresponds to GEJ in normal
subjects and many Consider that a hiatal hernia is present when
there is separation of> 2 cm between the SCJ and the diaphragmatic
indentation .29 However in the presence of columnar-lined
esophagus or Barrett's esophagus, SCJ is moved cranially and Tus
can not serve as a reliable marker. The upper margin of the gastric
folds Generally Accepted IS ALSO A marker used to identify
GEJ.36,37 Nevertheless, endoscopists sometimes have difficulty
identifying Clearly this marker. Another option is to use the distal
margin of the palisade zone to depict the GEJ. Palisade zone is the
longitudinally parallel capillaries running underneath the most
distal 2 to 3 cm of the esophageal epithelium.38 In 1966, de
Carvalho took a special interest in this vascular anatomy and its
illustrated schematically angioarchitecture dividing it into four
distinct zones zones.39 Reviews These were later named as truncal
zone, perforating zone, palisade zone and gastric zone.40,41 Based
on this anatomy, Hoshihara the patterns of GEJ classified into four
types According to the relationship among the distal margin of the
palisade zone, SCJ and the diaphragmatic indentation.42 In the first
type, the distal margin of the palisade zone, SCJ and the
diaphragmatic indentation (or pinchcock action) all fall at the same
level. In the second type, the distal margin of the palisade zone and
the diaphragmatic indentation lie at the same level but SCJ is
proximally located. In the third type, the distal margin of the
palisade zone and SCJ coincides but the diaphragmatic indentation
is found distal in relation to them. In the fourth type, SCJ is situated
proximal to both the distal margin of the palisade zone and the
diaphragmatic indentation. Since the distal margin of the palisade
zone is known to Correspond to the GEJ, 37,40,41 the third and
fourth types can be thought to meet the definition of a hiatal hernia
(Fig. 2). However, the palisade zone may not be visible in the
presence of inflammation of the squamous epithelium that overlies
the vasculature. In normal subjects, the SCJ, the upper margin of the
gastric fold and the distal margin of the palisade zone coincide and
approximate Generally the GEJ. Therefore, either of Reviews These
markers would be suitable for diagnosing a hiatal hernia
endoscopically, but in the presence of columnar-lined esophagus
and / or Barrett's esophagus, the distal margin of the palisade zone
would be more Appropriate Whenever it can be identified. There
are many limitations in using endoscopes to diagnose a hiatal hernia.
Measuring the size of hiatal hernia with incisors as the reference
point and using centimeter markings on the scope that is spaced
every 5 cm as a ruler can be said to lack in precision. The
mouthpiece or bite block hinders viewing Also the location of the
incisor if it is not transparent. Since the esophageal hiatus is
elliptically shaped and obliquely located, the distance from the tip
of the scope to incisor would vary along the circumference of the
opening. Although we usually look for the presence and Evaluate
the extents of hiatal hernia during insertion of the endoscopes with
minimum insufflations of water, there are still confusions as to when
(during insertion or removal of the endoscopes) or at the which
phase of respiration measurements should be made, or how much
water should be insufflated. To make matters worse to, retching or
belching of the Patients during examination can alter the location
and anatomy of GEJ. Furthermore, even when the measurements are
made, there can be a great degree of inter- and intra-observer
variation among endoscopists, Thus lacking in reproducibility.43
Due to Reviews These limitations,
2. Pathways:
Action increase LES pressure Defects weakness in the diaphragm Muscle weakness and loss of
hiatus diaphragmatic hiatus elastsitas
Preprocedural Planning
Obtain a complete history and perform a physical examination to determine
whether EGD is appropriate. Document findings in the patient's medical record.
Direct special attention to certain illnesses that might bear a direct effect on
endoscopy, such as cardiovascular and pulmonary diseases. Obtain a history of
drug allergies and previous abdominal surgeries.
Preprocedural testing in selected cases might include, but is not limited to, a
complete blood count (CBC), blood crossmatching, coagulation studies, a
chemistry panel, urinalysis, pregnancy testing, electrocardiography (ECG), and
chest radiography. No data support routine laboratory testing prior to elective
outpatient endoscopy. Preprocedural tests should be individualized and based on
information obtained from the patient's history and physical examination and the
indication for the procedure.
Equipment
Endoscopes are available from several different manufacturers (eg, Olympus,
Pentax, and Fujinon). The conventional endoscope consists of an umbilical cord, a
control head (with wheels for up/down and left/right, an air/water button, and a
suction button), an insertion tube 100 cm in length and 8-11 mm in external
diameter, and a bending section at the tip (which allows up to 180° deflection for
retroflexion of the endoscope).
The endoscope contains a lumen for insufflation of air and water, a working channel
2-3 mm in diameter (or larger, for therapeutic endoscopes) used for suctioning and
passage of instruments, control wires for moving the tip of the endoscope, and an
imaging system that is either fiberoptic (rare) or video (widely available). The
endoscope, light source, and image source (either a video monitor or a direct view
through the eyepiece) are essential equipment. Images and video can be recorded
and printed, depending on the equipment used.
Flexible ultrathin fiberoptic and video endoscopes that can be used without sedation
are also available for EGD. These endoscopes are inserted transnasally or perorally
and have a working length of 925-1050 mm, an external diameter of 5.3-6 mm, and
a working channel diameter of 2 mm.
Multiple instruments can be introduced through the working channel of the
endoscope, including biopsy forceps, snares, sclerotherapy needles, heater probes,
electrocautery probes, balloon-dilation devices, nets, and baskets. Guide wires can
be placed, and when the endoscope is withdrawn, wire-guided bougie dilators can
be passed. Devices can also be placed onto the end of the endoscope for banding of
esophageal varices and endoscopic mucosal resection (EMR).
Some of the newer endoscopes provide high resolution and magnifying endoscopy
and are used for the evaluation of certain upper GI diseases. The upper
gastrointestinal (GI) endoscope is also used to guide endoscopic treatment of
gastroesophageal reflux disease (GERD), [18] as with the Bard EndoCinch
endoscopic suturing device and the NDO full-thickness plicator.
A potentially useful advance in video endoscopy is narrow-band imaging
(NBI). [19, 20, 21] NBI uses optical filters and high relative intensity of blue light for
imaging and characterization of mucosal morphology, such as mucosal and
superficial vascular patterns. NBI has been studied in patients with Barrett
esophagus, early gastric tumors, and colorectal lesions and has had promising
results.
Endoscopy Cameras
Insufflators
Gastroscopes
Colonoscopes
Medical Scopes
Electrosurgical Units
Patient Preparation
Anesthesia
Conscious sedation and topical anesthesia are commonly used for EGD. The use of
monitored anesthesia care and propofol is gaining wide acceptance because of the
short recovery time. However, in many other countries, EGD is performed with
topical anesthesia only.
Topical anesthesia (eg, with Cetacaine [Cetylite Industries, Pennsauken, NJ] or
lidocaine) has the advantages of requiring less time for the overall procedure,
eliminating the risk of sedation, and decreasing the cost of the procedure by
reducing or eliminating recovery time and nursing staff. [24] The disadvantages are
patient discomfort and problems in performing the procedure on a patient who may
not be still.
With the cost-saving trends in medicine, EGD without sedation will likely become
more commonplace in the United States. With the introduction of smaller-caliber
endoscopes that can be passed through the nose, EGD without sedation may be
more acceptable to patients.
When conscious sedation is being administered, the patient must be monitored
throughout the procedure. Pulse oximetry, heart rate, and blood pressure are
commonly monitored. [25]
ECG monitoring is recommended in patients with cardiopulmonary disease, in
elderly patients, and during a prolonged procedure.
Agents that may be used in EGD include the following:
Benzodiazepines - Midazolam, diazepam
Opioids - Meperidine, fentanyl
Reversal agents - Flumazenil, naloxone
Midazolam is a sedative/hypnotic commonly used for sedation in endoscopic
procedures. The peak effect of midazolam is 3-5 minutes, with a duration of action
of 1-3 hours. Some of the major adverse effects include respiratory depression,
hypotension, and paradoxical agitation. The typical starting dose is 0.5-2 mg
intravenously (IV), which can be titrated to achieve a desirable level of sedation
(usually in 1-mg increments). Lower doses of midazolam should be administered
to elderly patients with cardiopulmonary problems to avoid serious complications.
Diazepam may be used instead of midazolam for sedation during endoscopic
procedures, but many centers prefer midazolam to diazepam because of its amnestic
effect and reduced tendency to cause phlebitis.
Meperidine is a narcotic analgesic that has mild sedative properties, slow onset of
action, long duration, and long recovery time. When coadministered with
benzodiazepines, potential complications include respiratory depression and
sedation. The peak effect of meperidine is approximately 10 minutes, with a
duration of action of 2-3 hours. Adverse effects include respiratory depression,
hypotension, nausea, and vomiting. The typical starting dose is 15-50 mg IV, with
subsequent individual doses not to exceed 25 mg.
Fentanyl is a mildly sedative narcotic analgesic that has a rapid onset of action and
short recovery time. In many endoscopy centers, fentanyl is the preferred agent for
outpatient endoscopic procedures. The peak effect is 5-8 minutes, and the duration
of action is 1-3 hours. One of the major adverse effects is respiratory depression.
The typical starting dose is 0.03-0.1 mg IV, with subsequent doses of 0.02-0.05 mg.
Flumazenil is typically used for reversal of benzodiazepine-induced sedation and
respiratory depression. Flumazenil has a peak effect of 3-5 minutes and a duration
of action of 1-2 hours. Potential adverse effects include resedation and seizures.
The typical dose is 0.2-0.5 mg IV for reversal of sedation (up to 1 mg total) and 1-
3 mg IV for benzodiazepine overdose.
Naloxone reverses opioid-induced analgesia, central nervous system (CNS) effects,
and respiratory depression. Naloxone has a peak effect of 1-2 minutes and a
duration of action of 1-3 hours. Adverse effects include pain, agitation, nausea,
vomiting, arrhythmias, sudden death, pulmonary edema, and withdrawal syndrome
in patients with opioid abuse. The typical dose is 0.04 mg IV for reversal of
analgesia/sedation and 0.4 mg for narcotic overdose and respiratory arrest.
Other agents that have been tried include propofol and dexmedetomidine. In a study
comparing propofol with dexmedetomidine in patients undergoing EGD under
conscious sedation, Wu et al found that both agents offered a relatively satisfactory
level of sedation without causing clinically notable adverse effects. [26] Propofol
was preferred by patients because of the deeper sedation and rapid recovery, and
dexmedetomidine had minimal adverse effects on respiratory function.
Positioning
The patient is usually placed in the left lateral position for this procedure.
Monitoring & Follow-up
After completion of a procedure performed with the patient under conscious
sedation, transfer the patient to a recovery room for further monitoring by an
endoscopy nurse.
Once the patient is alert and mobile (after ~1 hour), the patient may be allowed to
leave the recovery room with an escort. Give the patient postprocedural instructions
(eg, regarding diet and activity), and advise him or her to watch for signs and
symptoms of GI bleeding, fever, and abdominal pain.
A follow-up appointment with the primary care physician and/or the endoscopist is
usually arranged before the patient's discharge from the endoscopy unit.
Pre Prosedure
1. Patient arrived at endoscopy unit around 08:30Am from mulu ward and was
placed at the waiting bay/recovery bay and being monitor by the endoscopy
staff that being assign in that location
2. Assesment/interview session being done by the gastroenteriologist assistant
according the policy assessment patien in endoscopy. Arrival at the
recovery bay , observation had been done.
Report :
1. Oesophagus : Normal Mucosa, no oesophagitis, moderate hiatus hernia, no
mass lesion seen. Z-line at 38 cm from incisor
2. Stomach : nodural and body mucosa, superfacial ulcer antrum, no mass
lesion seen.
Biopsies x2 for urine positive
3. Duodenum : Nodular Mucosa D1, normal, D2, no ulcer or peri-ampularry
mass seen.
Post Procedures
Keep the patien on his side until fully awake and able to control secretion.
NO Diagnosis and data PURPOSE / CRITERIA Nursing care plan
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CA et al. (2013). Perez and Brady's Principles and Practice of Radiation
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Martini FH, Timmons MJ, Tallitsch RB. (2012). Human Anatomy. (7th Edition).
San Francisco: Pearson Benjamin Cummings.
National Cancer Institute. (2009, October 15). What You Need to Know About
Stomach Cancer. Bethesda, MD: National Cancer Institute.