- Anamnese include:
- Name :
- Age :
- Gender :
- Type of work :
- Address :
- Tribe / Nation :
- Religion :
- The level of education: for those with low education level / low gain knowledge of gastritis, it will underestimate the disease, even just think of gastritis as upset stomach and will eat regular foods that can cause and exacerbate the disease.
- History of illness and health
- The main complaint: Pain in the pit of the stomach and lower right abdomen.
- History of the disease at this time: Covers the journey of illness, initial symptoms are felt from the client, complaints arise suddenly or gradually felt, trigger factors, efforts to resolve the issue.
- Past history of disease: Includes diseases associated with the disease now, history of the hospital, and a history of drug use.
- Name :
- Physical examination, the Review of systems (ROS)
General condition: there was pain on physical examination there is tenderness in the epigastric quadrants.
- B1 (breath): tachypnea
- B2 (blood): tachycardia, hypotension, dysrhythmias, weak peripheral pulses, peripheral charging slow, pale skin color.
- B3 (brain): headache, weakness, level of consciousness can be disturbed, disorientation, pain epigastrum.
- B4 (bladder): oliguria, fluid balance disorders.
- B5 (bowel): anemia, anorexia, nausea, vomiting, heartburn, intolerance to spicy foods.
- B6 (bone): fatigue, weakness
- Assessment Focus
- Activity / Rest
Symptoms: weakness, fatigue
Signs: tachycardia, tachypnea / hyperventilation (in response to activity)
Symptoms: weakness, sweating
- Hypotension (including postural)
- Tachycardia, dysrhythmias (hypovolemia / hypoxemia)
- Weak peripheral pulse
- Slow capillary refill (vasoconstriction)
- Skin color pale, sianosis (depending on the number of blood loss)
- Weakness of skin / mucous membranes, sweating (shows status of shock, acute pain, psychological responses)
- Ego integrity
Symptoms: acute or chronic stress factors (financial, labor relations), feelings of helplessness.
Sign: a sign of anxiety, such as anxiety, pallor, sweating, narrowing of attention, shaking, trembling voice.
Symptoms: a history of previous hospitalization due to bleeding gastroenteritis (GE) or problems associated with GE, such as injury or gastric ulcer, gastritis, gastric surgery, gastric irradiation area. Changes in bowel habit / characteristic stool.
- Abdominal tenderness, distention
- Bowel sounds: often hyperactive during hemorrhage, hypo-active after the bleeding.
- The characteristics feses: diarrhea, blood color of dark, brownish or sometimes red bright, foamed, odor rotten (steatorrhoea), constipation can occur (a change diet, the use of antacids).
- Urinary output: decreased, concentrated.
- Food / fluid
- Anorexia, nausea, vomiting (throwing up that extends beyond the pyloric obstruction suspected in connection with a duodenal injury),
- Swallowing problems: hiccups
- Heartburn, sour belching, nausea or vomiting
Symptoms: flavor pulsed, dizziness / sick heads because of rays, weakness.
Sign: the level of consciousness can be impaired, the range of slightly inclined to sleep, disorientation / confusion, fainting and coma (depending on the volume of circulation / oxygenation).
- Pain / Comfort
- Pain, described as a sharp, shallow, burning, stinging, sudden severe pain may be accompanied by perforation. Sense of discomfort / distress faint after eating a lot and lost with a meal (acute gastritis).
- Pain epigastrum left until the middle / back or spread to occur 1-2 hours after eating and relieved by antacids (gastric ulcers).
- Pain left to epigastrum / or spread to his back occurred approximately 4 hours after eating when the stomach is empty and relieved by food or antacids (duodenal ulcer).
- No pain (esofegeal varices or gastritis).
- Trigger factors: food, cigarettes, alcohol, the use of certain drugs (salicylates, reserpine, antibiotics, ibuprofen), psychological stressors.
Symptoms: allergy to the drug / sensitive
Sign: an increase in temperature, spider angioma, palmar erythema (showing cirrhosis / portal hypertension)
- Guidance / Learning
Symptoms: the use of prescription drugs
- Activity / Rest