patient with insulin subcutan

GASTROPARESIS PADA PASIEN DENGAN DM

Gastroparesis means stomach (gastro) paralysis (paresis). A condition associated with diabetes, in which the emptying of the stomach is slowed. Other Terms used to describe this condition are: gastric stasis, gastropathy, slow stomach, sluggish stomach, diabetic enteropathy. Normally, the digestion of food is facilitated by steady, rhythmic contractions of the stomach muscles that break down food into smaller particles. These muscle contractions are also what push food into the small intestine, where it is further digested and its nutrients absorbed.
After having diabetes for many years, some people develop a condition known as diabetic autonomic neuropathy, in which the nerves that control automatic functions in the body, such as heartbeat and digestion, are damaged. If the vagus nerve, which controls the movement of food through the digestive tract, is damaged, the stomach and intestinal muscles may not function properly, and the passage of food through the digestive tract may be slowed. (http://www.diabetesselfmanagement.com/articles/Diabetes_Definitions/Gastroparesis/)

Symptoms of gastroparesis
· Nausea
· Vomiting
· An early feeling of fullness when eating
· Weight loss
· Abdominal bloating
· Abdominal discomfort
· Some other signs and symptoms include weight loss, erratic blood glucose levels, lack of appetite, gastroesophageal reflux (stomach contents backing up into the esophagus), and spasms of the stomach wall.
These symptoms may be mild or severe, depending on the person.
Other causes of gastroparesis
anorexia nervosa
surgery on the stomach or vagus nerve
postviral syndromes
certain medications, particularly those that slow contractions in the intestine
smooth muscle disorders, such as amyloidosis and scleroderma
diseases of the nervous system, such as abdominal migraine and Parkinson's disease
metabolic disorders, including hypothyroidism
Diagnosis
The diagnosis of gastroparesis is confirmed through one or more of the following tests:
Barium x-ray: After fasting for 12 hours, you will drink a thick liquid called barium, which coats the inside of the stomach, making it show up on the x-ray. Normally, the stomach will be empty of all food after 12 hours of fasting. If the x-ray shows food in the stomach, gastroparesis is likely. If the x-ray shows an empty stomach but the doctor still suspects that you have delayed emptying, you may need to repeat the test another day. On any one day, a person with gastroparesis may digest a meal normally, giving a falsely normal test result. If you have diabetes, your doctor may have special instructions about fasting.
Barium beefsteak meal: You will eat a meal that contains barium, thus allowing the radiologist to watch your stomach as it digests the meal. The amount of time it takes for the barium meal to be digested and leave the stomach gives the doctor an idea of how well the stomach is working. This test can help detect emptying problems that do not show up on the liquid barium x-ray. In fact, people who have diabetes-related gastroparesis often digest fluid normally, so the barium beefsteak meal can be more useful.
Radioisotope gastric-emptying scan: You will eat food that contains a radioisotope, a slightly radioactive substance that will show up on the scan. The dose of radiation from the radioisotope is small and not dangerous. After eating, you will lie under a machine that detects the radioisotope and shows an image of the food in the stomach and how quickly it leaves the stomach. Gastroparesis is diagnosed if more than half of the food remains in the stomach after 2 hours.
Gastric manometry: This test measures electrical and muscular activity in the stomach. The doctor passes a thin tube down the throat into the stomach. The tube contains a wire that takes measurements of the stomach's electrical and muscular activity as it digests liquids and solid food. The measurements show how the stomach is working and whether there is any delay in digestion.
Blood tests: The doctor may also order laboratory tests to check blood counts and to measure chemical and electrolyte levels.
Nursing intervention
§ Positioning
Patients may try sitting up after meals and maybe even go for a walk depending on how they feel.
Dietary modificationsChanging eating habits can also help control gastroparesis. Sometimes, eating six smaller meals a day is more effective than eating three larger ones. Some physicians recommend several liquid meals a day until blood glucose levels are stable and gastroparesis is stable. Your physician may also recommend avoiding fatty and high-fiber foods, as these can slow digestion and be difficult to digest. It is important to consult your physician or dietitian for the best eating plan for your condition. Botulinum toxin has also been shown to improve symptoms when injected directly into the pyloric sphincter.
Diet suggestion to clients
Getting Started
• Eat six or more small meals per day; avoid large meals.
• Avoid foods high in fat or too much fat added to foods (liquid fat in beverages is often
tolerated).
• Eat nutritious foods first before filling up on “empty calories.”
• Chew foods well; solid food, such as meat may be better tolerated if ground or puréed.
• High-fiber foods should be avoided because they may be more difficult for your stomach to empty or may cause bezoar formation. A bezoar is a mixture of food fibers that may get stuck in a stomach that does not empty well, similar to a hairball in a cat). Examples of high fiber foods: All bran, popcorn, broccoli, beans.
• Sit up while eating and for 1 hour after finishing; consider taking a quiet walk after meals.
• If you have diabetes, try to keep your blood sugar well controlled. Let your doctor know if your blood sugar runs >200 on a regular basis.

Tips for Maintaining your Diet
• Solid food is more work for the stomach to empty than liquids. On days when symptoms are worse; try taking just liquids to let the stomach rest. Any food may be used if it is liquefied, thinned, or blenderized and strained.
• Check your weight twice a week. If weight is decreasing, increase the amount of liquid supplements or caloric beverages consumed like milkshakes, popsicles, gelatin, etc. If you lose more than 10 pounds unintentionally, let your doctor know.
• At meals take puréed foods and liquid supplements before coffee, tea or soda.

Blenderized Food
• Any food can be blenderized, but solid foods will need to be thinned with some type of liquid.
o Meats, fish, poultry, ham: blend with broths, water, milk, vegetable or V-8 juice, tomato sauce, gravies.
o Vegetables: Blend with water, tomato juice, broths, strained baby vegetables.
o Starches: potatoes, pasta: Blend with soups, broth, milk, water, gravies; add strained baby meats, etc to add protein if needed. Consider using hot cereals such as cream of wheat or rice, grits, etc as your “starch” at lunch and dinner.
o Fruits: Blend with its own juice, other fruit juices, water, strained baby fruits.
o Cereals: Make with caloric beverage such as whole milk, soy or rice milk, juice, Ensure or equivalent, etc., instead of water. Add sugars, honey, molasses, syrups, or other flavorings, butter or margarine for extra calories.
o Mixed dishes: Lasagna, macaroni and cheese, spaghetti, chili, chop suey – add adequate liquid of your choice, blend well and strain.
• If the blenderized item comes out “lumpy”, you can strain it through a fine metal kitchen strainer (get at a kitchen store, Wal-Mart, etc) or cheesecloth (a fine material available at most fabric stores)
• If you do not have a blender, strained baby foods will work and can be thinned down as needed with milk, soy or rice milk, water, broth, etc.
• Always clean the blender well. Any food left on the blender could cause food poisoning.

§ Dental Health
Since gastroparesis impairs the stomach’s ability to mash food and break it down into smaller sizes in preparation for absorption, the chewing of food beforehand becomes even more important. In addition, repeated exposure to stomach acid from frequent vomiting may destroy tooth enamel. Parrish Carol Rees(2003)

Collaboratives
§ MedicationsSeveral medications are used to treat gastroparesis. Your physician may prescribe combinations of medications or different medications to determine which is the most effective. The medications available include Metoclopramide, Erythromycin, Cisapride, Domperidone, and Tegaserod.
Metoclopramide is a medication that acts on dopamine receptors in the stomach and intestine as well as in the brain. This medication can stimulate contraction of the stomach that leads to improvement in emptying. This medication also has the effect of acting on the part of the brain responsible for controlling the vomiting reflex and therefore may decrease the sensation of nausea and the urge to vomit. Use of this medication is limited in some people due to the side effects of agitation and facial twitching or “tardive dyskinesia”. Metoclopramide can also cause painful breast swelling and nipple discharge in both men and women. It is not recommended that this medication be taken long term.
Domperidone is another medication that acts on dopamine receptors. Domperidone is not available in the United States but is used in Mexico and Canada and in some European countries.
Erythromycin is a commonly used antibiotic that binds to receptors in the small intestine and stomach called “motilin receptors”. Stimulation of motilin receptors results in contraction and improved emptying of the stomach. The beneficial effect of erythromycin can be short lived as individuals who use it frequently have a high likelihood of developing tolerance to the medication. Perhaps the best use of erythromycin is for a worsening of symptoms or used on an intermittent basis to reduce the potential for tolerance.
Cisapride binds to serotonin receptors located in the stomach wall that leads to contraction of stomach smooth muscle and improved gastric emptying. In the late 1990’s Cisapride was removed from the market due to complications of cardiac arrhythmias found in patient’s with a history of arrhythmia or coronary artery disease who were using the therapy. It is once again available but its use is restricted. Individuals with underlying kidney or heart disease should not use Cisapride.
Botulinum toxin has also been shown to improve symptoms when injected directly into the pyloric sphincter.
surgeryOccasionally, when other approaches fail, it is necessary to perform a surgical procedure called jejunostomy, in which a feeding tube is inserted through the skin on the abdomen into the small intestine. This tube then allows nutrients to be put directly into the small intestine, bypassing the stomach. This is used only when gastroparesis is severe and prevents the nutrients and medications necessary to regulate blood glucose levels from reaching the bloodstream.
A new surgically implanted device, known as a "gastric neurotransmitter," may also be used to control nausea and vomiting.


Figure 1 Gastrostomy and jejunostomy anatomy
Figure 2 Oro-jejunal feeding tube

Gastric Electrical Stimulation
A gastric neurostimulator is a surgically implanted battery-operated device that releases mild electrical pulses to help control nausea and vomiting associated with gastroparesis. This option is available to people whose nausea and vomiting do not improve with medications. Further studies will help determine who will benefit most from this procedure, which is available in a few centers across the United States.
parenteral nutritionAn alternative to the jejunostomy tube is parenteral nutrition, in which nutrients are delivered directly into the bloodstream, bypassing the digestive system. The physician places a catheter in a chest vein, leaving an opening on the outside of the skin. A bag with liquid nutrients or medication can be attached to the catheter, allowing the fluid to enter the bloodstream through the vein.
Sumber : www.digestive.org, www.gi.org/patients/gihealth/gastroparesis.asp

my inspiration

my inspiration

Prosedur Plebotomi pada Pasien Polisitemia

VENIPUNCTURE PROCEDURE
The venipuncture procedure is complex, requiring both knowledge and skill to perform. Each phlebotomist generally establishes a routine that is comfortable for her or him. Several essential steps are required for every successful collection procedure:
1. Identify the patient.
2. Assess the patient's physical disposition (i.e. diet, exercise, stress, basal state).
3. Check the requisition form for requested tests, patient information, and any special requirements.
4. Select a suitable site for venipuncture.
5. Prepare the equipment, the patient and the puncture site.
6. Perform the venipuncture.
7. Collect the sample in the appropriate container.
8. Recognize complications associated with the phlebotomy procedure.
9. Assess the need for sample recollection and/or rejection.
10. Label the collection tubes at the bedside or drawing area.
11. Promptly send the specimens with the requisition to the laboratory.
PROCEDURE FOR VEIN SELECTION:
· Palpate and trace the path of veins with the index finger. Arteries pulsate, are most elastic, and have a thick wall. Thrombosed veins lack resilience, feel cord-like, and roll easily.
· If superficial veins are not readily apparent, you can force blood into the vein by massaging the arm from wrist to elbow, tap the site with index and second finger, apply a warm, damp washcloth to the site for 5 minutes, or lower the extremity over the bedside to allow the veins to fill.
PERFORMANCE OF A VENIPUNCTURE:
· Approach the patient in a friendly, calm manner. Provide for their comfort as much as possible, and gain the patient's cooperation.
· Identify the patient correctly.
· Properly fill out appropriate requisition forms, indicating the test(s) ordered.
· Verify the patient's condition. Fasting, dietary restrictions, medications, timing, and medical treatment are all of concern and should be noted on the lab requisition.
· Check for any allergies to antiseptics, adhesives, or latex by observing for armbands and/or by asking the patient.
· Position the patient. The patient should either sit in a chair, lie down or sit up in bed. Hyperextend the patient's arm.
· Apply the tourniquet 3-4 inches above the selected puncture site. Do not place too tightly or leave on more than 2 minutes.
· The patient should make a fist without pumping the hand.
· Select the venipuncture site.
· Prepare the patient's arm using an alcohol prep. Cleanse in a circular fashion, beginning at the site and working outward. Allow to air dry.


· Grasp the patient's arm firmly using your thumb to draw the skin taut and anchor the vein. The needle should form a 15 to 30 degree angle with the surface of the arm. Swiftly insert the needle through the skin and into the lumen of the vein. Avoid trauma and excessive probing.
· When the last tube to be drawn is filling, remove the tourniquet.
· Remove the needle from the patient's arm using a swift backward motion.
· Press down on the gauze once the needle is out of the arm, applying adequate pressure to avoid formation of a hematoma.
· Dispose of contaminated materials/supplies in designated containers.
· Mix and label all appropriate tubes at the patient bedside.
· Deliver specimens promptly to the laboratory.