CHAPTER I

PRELIMINARY

A. Background
Nowadays the more modern times, the more diseases that arise due to human
lifestyles and due to natural factors. One of them is Akalasia disease which occurs
due to a decrease in function of the esophagus which makes choking occur
frequently when eating or drinking, this disease cannot be contagious but can occur
in all sexes.
This achalasia is more attacking on people who are elderly so they need
special care because it will prevent the old age of all of us, so we need knowledge
to treat and better to prevent the occurrence of this disease early.
Therefore, this disease is very interesting to discuss because it is very close to
our daily lives. This disease can certainly damage the psychological and
psychosocial aspects of the sufferer, and holistic nursing care and health education
are needed to prevent this disease.

B. Problem Statements
1. What is the definition of Akalasia?
2. What is the anatomy and physiolosi of the esophagus?
3. What is the cause of Akalasia?
4. What is the course of the disease from Achalasia?
5. What are the signs and symptoms of Achalasia?
6. What are the complications of Achalasia?
7. What is the diagnostic test for Achalasia?
8. What are the medical and non-medical treatments for Achalasia?

1
C. Purpose
1. The main purpose
In order for nursing students to know what the concepts of dengue fever
start from understanding to appropriate nursing care in patients with dengue
fever.
2. The special purpose
a. To find out the definition of Akalasia
b. To find out the anatomy and physiolosi of the esophagus
c. To find out the cause of Akalasia
d. To find out the course of the disease from Akalasia
e. To find out the signs and symptoms of Achalasia
f. To find out complications from Akalasia
g. To find out the diagnostic examination of Achalasia disease
h. To find out medical and non-medical management of Acalacia disease

D. Writing Method
The method of writing this paper uses a descriptive method in which the author
looks for references to Achalasia from several books and the internet.

E. Writing system
In this scientific paper, the author uses a four-chapter system, namely :
Chapter I, Introduction that contains background, problem formulation,
purpose, writing method and writing systematics.
Chapter II, Basic concepts that contain understanding, causes, anatomy and
physiology, signs and symptoms, complications, diagnostic tests
and management.
Chapter III, Nursing care that contains assessment, data analysis, nursing
diagnosis and planning.
Chapter IV, Finility containing conclusions and suggestions.

2
 CHAPTER II
REVIEW OF THEORY

A. Definition
Achalasia is a rare disease of the esophageal muscle (the tube that swallows).
The term achalasia means "failure to relax" and refers to the inability of the lower
esophageal sphincter (muscle ring between the lower esophagus and stomach) to
open and let food pass into the stomach. As a result, patients with achalasia have
difficulty swallowing food. (www.totalkesehatananda.com, 2010).
Achalasia is the absence or ineffectiveness of distal esophageal peristaltic
accompanied by failure of the esophageal sphincter to relax in response to
swallowing (Brunner & Suddarth (2002).
Failure to relax the esophagogastric limit in the process of swallowing causes
dilatation of the proximal part of the esophagus in the absence of peristalsis.
Achalasia sufferers feel the need to push or force food with water or drinks to
improve the process of swallowing and other symptoms can be a feeling of full
substernal and regurgitation generally (Siegel, 1998 and Ritcher, 1999).

B. Anatomical Physiology

(www.google.com)

3
 The esophagus is a vertical muscular tract that connects the hypopharynx to
the stomach. The size is 23-25 cm long and about 2 cm wide (in the widest state)
in adults. The esophagus starts at the lower border of the cricoid cartilage about
the height of the cervical vertebra VI (Ballenger, 1997). From this limit, the
osefagus is divided into three parts, namely, pars cervical, pars thoracal and
abdominal pars. The esophagus will then end in the gastric cardia orifice at thoracal
vertebrae XI. There are four physiological constriction of the esophagus, namely,
narrowing of the cricopharyngeal sphincter, narrowing of the aortic crossing
(aortic arch), narrowing of the left bronchial crossing, and narrowing of the
diaphragm (esophageal hiatus).
The esophageal wall consists of 3 layers, namely: the mucosa which is a
squamous, submucosal epithelium made of elastic fibrous tissue and is the
strongest layer of the esophageal wall, the esophageal muscles consisting of the
inner circular muscle and the outer longitudinal part where 2/3 parts the upper part
of the esophagus is a skeletal muscle and 1/3 of the lower part is smooth muscle.
In the neck, the esophagus receives blood from a. internal carotid and tyroservical
trunk. The esophagus is innervated by sympathetic and parasympathetic
innervation (vagus nerve) of the esophageal plexus or commonly called the
Auerbach myenteric plexus which is located between the longitudinal muscle and
the circular muscle along the esophagus.
Esophagus has 3 functional parts. The upper part is the upper esophageal
sphincter (upper esophageal sphincter), a muscle ring that forms the upper part of
the esophagus and separates the esophagus from the throat. This sphincter always
closes to prevent food from the main part of the esophagus from entering the throat.
The main part of the esophagus is referred to as the body of the esophagus, a
muscular duct which is approximately 20 cm long. The third functional part of the
esophagus is the lower esophageal sphincter, a muscle ring located at the
confluence of the esophagus and stomach.

4
 Like the upper sphincter, the lower sphincter always closes to prevent food
and stomach acid from returning up / regurgitation into the esophageal body. The
upper sphincter will relax in the process of swallowing so that food and saliva can
enter the upper part of the esophageal body. Then, the muscles of the upper
esophagus located below the sphincter contract, pressing food and saliva further
into the esophagus. Contractions called mi peristalsis will bring food and saliva to
descend into the stomach. When this peristaltic wave reaches the lower sphincter,
it opens and food enters the stomach (Soepardi, 2001).
The esophagus functions to carry food, fluid, secretions from the pharynx to
the stomach through a process of swallowing, where there will be a formation of
bolus food with soft size and consistency, the process of swallowing consists of
three phases, namely :
1. Oral phase, food in the form of a bolus due to a mechanical process moving
on the dorsum of the tongue towards the oropharynx, the palate of the mole
and the upper part of the posterior pharyngeal wall raised.
2. Pharyngeal phase, involuntary swallowing, pharynx and fangs move up due
to contraction m. Stylofaringeus, m. Salipingopharynx, m. Thyroid and m.
Palatopharynx, laryngeal aditus enclosed by epiglottis and laryngeal
sphincter. 3. the oesophageal phase,
3. Phase swallow (involuntary) displacement of bolus food distally due to
relaxation m. Cricopharynx, at the end of the lower esophageal sphincter
phase opens and closes again when the food has passed.

5
 The anatomy of the digestive tract consists of the mouth, throat, esophagus,
stomach, small intestine, large intestine, rectum and anus

The physiology of the digestive system or gastroinstestinal system (starting

from the mouth to the anus) is an organ system in humans that functions to receive
food, digest it into nutrients and energy, absorb nutrients into the bloodstream and
dispose of food that cannot be digested or is the next process of the body. Anatomy
and physiology of the digestive system, namely:
1. Mouth
It is an open place for food and air to enter. The mouth is the initial part of
the complete digestive system and the entrance to the digestive system which
ends in the anus. The inside of the mouth is regulated by mucous membranes.
The tasting felt by the taste organs on the surface of the tongue. Simple tasting
consists of sweet, sour, salty and bitter. Smelling experienced by the olfactory
nerve is made up of a variety of odors. Food is cut into pieces by the front teeth
(incisors) and chewed by the back teeth (molar, molars), into smaller parts that
are easier to digest. Digestive saliva will wrap the parts of the food with

6
 digestive enzymes and start digesting them. Saliva also contains antibodies and
enzymes (such as lysozyme), which break down proteins and attack bacteria
directly. The process starts automatically.
2. Throat
Is a link between the oral cavity and esophagus. Inside the pharyngeal arch
contains tonsils (lymph tonsils) that are lymph which contain many
lymphocytes and are a defense against infection, here are located in contact
with the airway and food path, behind the oral cavity and nasal cavity, in front
of the nasal passages, with koana holes, bond holes with a hole with a hole
called ismus fausium. The pharynx consists of the superior part which is the
same height as the nose, the part of the media that is the same height as the
mouth and the inferior part which is the same height as the larynx. The superior
part is called the nasopharynx, in the nasopharynx empties into the tube that
connects the pharynx to the eardrum space. Media section called the
oropharynx, this part is bounded forward to the root of the tongue. The inferior
part is called the laryngopharynx which connects the oropharynx to the larynx.
3. Esophagus
The esophagus is a muscular tube (tube) in vertebrates that is passed when
food flows from the mouth into the stomach. Food goes through the esophagus
using a peristaltic process. The esophagus meets the pharynx in the 6th segment
of the spine. According to histology, the esophagus is divided into three parts,
namely the superior part (mostly the skeletal muscle), the middle part (a mixture
of skeletal muscle and smooth muscle), and the inferior part (mainly composed
of smooth muscle).
4. Stomach
Is a large hollow muscle organ, which consists of three parts, namely cardia,
fundus and antrium. The stomach functions as a food storehouse, which
contracts rhythmically to mix food with enzymes. The cells lining the stomach
produce 3 important substances, namely mucus, hydrochloric acid (HCL), and

7
 precursor pepsin (enzymes that break down proteins). Mucus protects stomach
cells from damage by stomach acid and hydrochloric acid creates a very acidic
atmosphere, which is needed by pepsin to break down protein. High gastric
acidity also acts as a barrier to infection by killing various bacteria.
5. Small intestine (small intestine)
The small intestine or small intestine is a part of the digestive tract located
between the stomach and large intestine. The intestinal wall is rich in blood
vessels that transport substances that are absorbed into the liver via the portal
vein. The intestinal wall releases mucus (which lubricates the contents of the
intestine) and water (which helps dissolve fragments of digested food). The
intestinal wall also releases small amounts of enzymes that digest protein, sugar
and fat. The lining of the small intestine consists of the mucous layer (inside),
the circular muscle layer, the elongated muscle layer and the serous layer. The
small intestine consists of three parts, namely the duodenum, the empty
intestine (jejunum), and the intestinal absorption (ileum).
a. Intestine Twelve Fingers (Duodenum)
The twelve-finger intestine or duodenum is a part of the small intestine
located after the stomach and connects it to the empty intestine (jejunum).
The part of the twelve finger intestine is the shortest part of the small
intestine, starting with the duodenale bulbo and ending in the ligament treitz.
The twelve-finger intestine is a retroperitoneal organ, which is not
completely encapsulated by the peritoneal membrane. A normal twelve-
finger bowel pH ranges from nine degrees. In the duodenum there are two
mouth channels, namely the pancreas and gallbladder. The stomach releases
food into the duodenum, which is the first part of the small intestine. Food
enters the duodenum through the inner pyloric sphincter amount that can be
digested by the small intestine. If it is full, the duodenum will send a signal
to the stomach to stop flowing food.

8
 b. Empty bowel
The empty intestine or jejunum is the second part of the small intestine,
between the duodenum and intestinal absorption (ileum). In adult humans,
the length of the entire small intestine is between 2-8 meters, 1-2 meters is
part of the empty intestine. The empty intestine and intestinal absorption are
hung in the body by the mesentery. The surface in the empty intestine is a
mucous membrane and there are jaws (villi), which expand the surface of
the intestine.
c. Intestine Absorption (Illeum)
Intestinal absorption or ileum is the last part of the small intestine. In the
human digestive system the ileum has a length of about 2-4 m and is located
after the duodenum and jejunum, and is continued by appendicitis. Ileum has
a pH between 7 and 8 (neutral or slightly alkaline) and functions to absorb
vitamin B12 and bile salts.
6. Colon (Colon)
The large intestine or colon is the part of the intestine between the
appendix and rectum. The main function of this organ is to absorb water from
the stool. The large intestine consists of ascending colon (right), transverse
colon, descending colon (left), sigmoid colon (associated with rectum). The
number of bacteria contained in the large intestine functions to digest some
ingredients and helps absorb nutrients. Bacteria in the large intestine also
function to make important substances, such as vitamin K. These bacteria are
important for normal function of the intestine. Some diseases and antibiotics
can cause interference with bacteria in the large intestine. The result is irritation
which can cause mucus and water to be released, and diarrhea occurs.
7. Rectum and Anus
The rectum is a room that starts from the tip of the large intestine (after the
sigmoid colon) and ends at the anus. This organ functions as a temporary

9
 storage place for feces. Usually this rectum is empty because the stool is stored
in a higher place, namely in the descending colon. If the descending colon is
full and the stool enters the rectum, then there is a desire to defecate. The
expansion of the rectal wall because the accumulation of material in the rectum
will trigger the nervous system which creates the desire to carry out defecation.
If defecation does not occur, often the material will be returned to the large
intestine, where the absorption of water will be carried out again. If the
defecation does not occur for a long period of time, stool constipation and
hardening will occur. Adults and older children can resist this desire, but babies
and younger children experience deficiencies in muscle control which are
important for delaying bowel movements. Anus is a hole in the end of the
digestive tract, where waste material comes out of the body. Some anus are
formed from the surface of the body (skin) and partly other from the intestine.
The opening and closing of the anus is regulated by the sphinkter muscle. Stool
is removed from the body through a process of defecation (defecation) which
is the main function of the anus (Pearce, 1999).

C. Etiology
The etiology of achalasia is not known exactly. However, there is evidence that
the Auerbach plexus degeneration causes loss of neurological regulation. Some
theories that develop are related to autoimmune disorders, infectious diseases or
both.
1. According to the etiology, achalasia can be divided into 2 parts, namely:
Primary escalation (most commonly found). The obvious cause is unknown.
Allegedly caused by neurotropic viruses and hereditary factors.
2. Secondary escalation (rarely found). This disorder can be caused by an
infection, an intraluminer tumor such as a cardia tumor or an extraluminer
pushing such as a pancreatic pseudocyst. Another possibility can be caused by
anticholinergic drugs or postcavagotomy.

10
 Based on the etiology theory :
1. Genetic theory The findings of achalasia cases in several people in one family
have supported that achalasia may be genetically inherited. This possibility
ranges from 1% to 2% of the population with achalasia.
2. Infection theory Related factors include bacteria (diphtheria pertussis,
clostridia, tuberculosis and syphilis), viruses (herpes, varicella zooster, polio
and measles), toxic substances (gas kombat), esophageal trauma and uterine
esophageal ischemia during rotation of the digestive tract intra uterine. The
strongest evidence supports the neurotropflc infection factor as etiology. First,
the specific location of the esophagus and the fact that the esophagus is the only
part of the digestive tract where the smooth muscle is covered by squamous cell
epithelium that allows infiltration of the infectious factor.
3. Autoimmune theory The discovery of an autoimmune theory for achalasia was
taken from several somber. First, the inflammatory response in the esophageal
myenteric plexus is dominated by T lymphocytes which are known to affect
autoimmune diseases. Second, the highest prevalence of class II antigens, which
are known to be associated with other autoimmune diseases. Finally, some cases
of achalasia are found to be autoantibodies from the myenteric plexus.
4. Degenerative theory Epidemiological studies from the US. found that achalasia
was associated with the aging process with neurological status or psychological
illness, such as Parkinson's disease and depression.
D. Pathophysiology
The contraction and relaxation of the lower esophageal sphincter is regulated
by stimulating neurotransmitters such as acetylcholine and substance P, as well as
inhibitory neurotransmitters such as nitrite oxyde and, vasoactive intestinal peptide
(VIP).
According to Castell there are two important effects on achalasia patients
1. Obstruction of the esophageal and gastric junction due to an increase in the
lower esophageal sphincter (SEB) breaks well above normal and the failure of

11
 SEB for perfect relaxation. Some authors cite an association between increased
SEB and sensitivity to the hormone gastrin. The human SEB length is 3-5 cm
while the normal basal SEB pressure is 20 mmHg. In achalasia the SEB
pressure increases by about twice or approximately 50 mmHg. The failure of
SEB relaxation is due to a decrease in pressure of 30-40% which normally falls
to 100% which will result in food boluses not being able to enter the stomach.
This failure results in retention of food and drinks in the esophagus. The
inability of perfect relaxation will cause residual pressure. If hydrostatic
pressure accompanied by gravity can exceed residual pressure, food can enter
the stomach.
2. Abnormal esophageal peristalsis caused by aperistaltic and dilated ⅔ lower part
of the esophageal corpus. As a result of weak and uncoordinated peristalsis, it
is not effective in pushing food boluses through SEB. With the development of
research in the direction of motility, objectively it can be determined that
esophageal motility is manometric in normal and achalasia conditions.

12
E. Pathway
Genetic Autoimmune age factor Virus infection
Inflammatory response Neurotropic
myenteric plexus

Nerve degeneration

Damage to the nerve work of the mientricus nexus

in the lower 2/3 of the esophagus

Muscle work decreases

Aperistalti

Upper esophageal pressure increases

Lower esophageal sphincter fails relaxation

Difficult to swallow
gastric reflex increases
AKALASIA

Food is stuck in the esophagus Acute pain

Backflow of food out

Eat drinking vomiting Gag

Change in health status Less / no nutrition intake Food enters the airways

Misinterpretation Response to coughing and sneezing

of information Nutritional needs:
Less than the body's
needs
Risk of
aspiration

13
Do not know the
source of information

Knowledge
deficiency

14
F. Clinical manifestations
Acalacia usually starts in young adults although there are also those found in
infants and very rare in old age. Usually the symptoms found are:
1. Dysphagia is a major complaint from people with Acalacia. Dysphagia can
occur suddenly after swallowing or if there is an emotional disorder. Dysphagia
can be temporary or progressively slow. Usually fluids are more difficult to
swallow than solid foods.
2. Regurgitation can occur after eating or when lying down. Frequent regurgitation
occurs at night when the patient is sleeping, which can lead to aspiration
pneumonia and lung abscess
3. Burning and Substernal Pain can be felt at the beginning of the stage. At an
advanced stage there will be severe pain in the epigastric region and this pain
can resemble an attack of angina pectoris.
4. Weight loss occurs because patients try to reduce their food to prevent
regurgitation and pain in the substernal area.
5. Another symptom that is commonly felt by sufferers is feeling full of substernal
and due to complications from food retention.

G. Complication
Some complications and achalasia are as follows:
1. Respiratory obstruction
2. Bronchitis
3. Aspiration pneumonia
4. Abscess the people
5. Diverticulum
6. Esophageal perforation
7. Small cell carcinoma

15
H. Diagnostic Check
Diagnosis of Esophageal Acalasia is based on clinical symptoms, radiological
features, esophagoscopy and manometric examination.
1. Radiological examination
Plain chest X-ray does not reveal air bubbles in the upper part of the
stomach, it can also show an air fluid level posterior to the mediastinum. Barium
esophagogram examination by fluoroscopy examination, appears to be dilated
in the distal two-thirds region of the esophagus with abnormal peristalsis and a
narrowing of the distal esophagus or esophagogastric junction that resembles a
bird-beak like appearanc. (Siegel, 1998 and Goyal, 1994)
2. Esophagoscopic examination
Esophagoscopy is a recommended examination for all achalasia patients
for several reasons, namely to determine the presence of retention esophagitis
and its severity, to see the cause of the obstruction, and to ensure the presence
or absence of signs of malignancy. On this examination, there is a widening of
the esophageal lumen with a distal narrowing, there are food debris and fluid in
the proximal part of the narrowing area, pale esophageal mucosa, edema and
sometimes signs of altered esophagitis in food retention. The lower esophageal
sphincter will open with a little pressure on the esophagoscope and the
esophagoscope can enter the stomach easily (Siegel, 1998 and Goyal, 1994).
3. Manometric Examination
The point is to supply the esophageal motor function by checking the
pressure inside the lumen of the esophageal sphincter. This examination shows
quantitative and qualitative motility abnormalities. Examination is done by
inserting a pipe for manometry through the mouth or nose. In the achalasia
assessed is the motor function of the esophageal body and lower esophageal
sphincter. The esophageal body is assessed for resting pressure and peristaltic
activity. The lower esophageal sphincter assessed is resting pressure and its
relaxation mechanism. The typical manometric feature is the increased pressure

16
 of the esophageal body, there is no peristaltic movement along the esophagus
as a reaction to the swallowing process. The lower esophageal sphincter
pressure is normal or elevated and no sphincter relaxation occurs during
swallowing.

I. Management
The therapeutic nature of achalasia is only palliative, because the esophageal
peristaltic function cannot be restored. Therapy can be done by giving a high-
calorie diet, medical, dilatation measures, psychotherapy, and
esophagocardiotomy surgery (Heller's surgery) (Siegel, 1998)
1. Non-surgical therapy
a. Medication Therapy
Giving smooth-muscle relaxants, such as nitroglycerin 5 mg SL or
10 mg PO, as well as methacholine, can lower the esophageal sphincter
relaxation and help distinguish between a distal esophageal stricture and a
contraction of the lower esophageal sphincter. In addition, calcium
channel blockers (nifedipine 10-30 mgSL) can also be reduced which can
reduce pressure on the lower esophageal sphincter.
However, only about 10% of patients succeed with this therapy. This
therapy should be used for elderly patients who have contraindications to
pneumatic dilatation or surgery.
b. Botulinum Toxin Injection
An injection of botulinum intrasfingter toxin can be used to inhibit
the release of acetylcholine in the esophageal sphincter
below, which will then restore the balance between excitation and
inhibition neurotransmitters. Using endoscopy, the toxin is injected using
a sclerotherapy needle that is inserted into the esophageal wall with a tilt
angle of 45 °, where the needle is inserted until the mucosa is about 1-2 cm
above the squamous column junction. The location of the needle injection

17
 is located just above the proximal limit of LES and the toxin is injected
caudally into the sphincter. The effective dose used is 80-100 units / mL
which is divided into 20-25 units / mL to be injected in each quadrant of
LES. The injection is repeated with the same dose 1 month later to get
maximum results. However, this therapy has a limited assessment where
60% of patients who have been treated still do not feel dysphagia 6 months
after therapy; this percentage then drops to 30% even after several
injections two and a half years later. In addition, this therapy often causes
an inflammatory reaction in the gastroesophageal junction, which in turn
can make the myotomy more difficult. This therapy should be used in
elderly patients who are less able to undergo dilation or surgery. (Finley,
2002 in Irwan, 2009).
c. Pneumatic Dilatation
Pneumatic dilatation has been a major form of therapy for years. A
baton is developed in the gastroesophageal junction that aims at luituk to
dislodge muscle fibers, and make the mucosa intact. The percentage of
initial success is between 70% and 80%, but will drop to 50% 10 years
later, even after several dilatations. The ratio of performance is around 5%.
If a perforation occurs, the patient is immediately taken to the operating
room for perforation and myotomy which is done by means of left
thoracotomy. The incidence of abnormal gastroesophageal reflux is
around 25%. Patients who fail treatment of pneumatic dilatation are
usually treated with Heller myotomy (Finley, 2002 in Irwan, 2009)
2. Surgical Therapy
A laparoscopic Heller myotomy and partial fundoplication is a
procedure of choice for esophageal achalasia. This operation consists of a
separation of muscle fibers (eg myotomy) from the lower esophageal
sphincter (5 cm) and the proximal part of the stomach (2 cm), followed by
partial fundoplication to prevent reflux. Patients are hospitalized for 24-48

18
hours, and return to daily activities after about 2 weeks. Effectively, this
surgical therapy is successful in reducing the symptoms of about 85-95% of
patients, and the incidence of postoperative reflux is between 10% and 15%.
Due to excellent success, short hospital care, and rapid recovery time, this
therapy is considered the main therapy in the management of esophageal
achalasia. Patients who fail this therapy may need dilatation, second surgery,
or removal of the esophagus eg esophagectomy (Marks, 2005 in Irwan, 2009)

19
 BAB III
NURSING CARE
A. Assesment
1. Client Identity
Name, age, gender, occupation, entry date, address, MR number, etc.
2. Health History
a. Previous Medical History
Usually clients have experienced upper gastrointestinal disease.
b. Current Health History
Usually the client experiences dysphagia, regurgitation, pain behind the
sternum, anorexia and decreased body weight.
c. Family Health History
The presence or absence of family members who suffer from the same
disease as the client.
3. Physical Examination
a. Head and Neck
Usually the hygiene of the head is maintained and the neck usually does not
have enlarged lymph nodes
b. Eye
Usually the conjunctiva is not anemic, the sclera is not jaundiced and the
palpebra is not edema.
c. Nose
Usually no abnormalities are found
d. Mouth
Usually oral and dental hygiene is maintained and the lips mucosa is dry
e. Ear
Usually abnormalities are not found

20
 B. Data Analysis

DATA ANALYSIS

NO DATA ETIOLOGY NURSING PROBLEMS

1 DS: - Patients say no appetite Food is stuck in the esophagus Nutritional needs: Less than needed
- The patient says pain
DO: - The patient looks weak
- The patient's face is Backflow of food comes out
pale
- Dry lip mucosa
- The patient looks thin Gag
- TTV: TD (120/70)
RR (22x / m)
P (80x / m) Intek nurisi is lacking / missing
T (38 c)

Nutritional needs : less

than needed

2 DS: - The patient says pain Backflow of food comes out Acute pain
DO: - The patient looks weak
- The patient's face is
Increased gastric reflex
pale
- The patient looks
grimace

21
 - The patient appears to
Acute pain
be moderately ill
- TTV: TD (120/70)
RR (22x / m)
P (80x / m)
T (38 c
3 DS: - Patients say that they Gag Risk of aspiration
often choke until the
food is swallowed but
enters the nasal cavity Food enters the airways
so the patient coughs
and sneezes while
eating Response to coughing and sneezing
DO: - Patients with difficulty
swallowing, decreased
consciousness
Risk of
- Hypersaliva in the
mouth aspiration
- TTV: TD (120/70)
RR (22x / m)
P (80x / m)
T (38 c
4 DS: - Patients say they do not Change in health status Knowledge deficiency
know that they often
have sore throats and
dizziness Misinterpretation of information
- The patient says he
often feels his body is
Do not know the source of information

22
 limp and has no
appetite

DO: - Patients express Knowledge

verbally interested in deficiency
the explanation of their
current health condition
and want further
explanation.
- TTV: TD (120/70)
RR (22x / m)
P (80x / m)
T (38 c)

23
 C. Nursing Care Plan

NURSING CARE PLAN

NO NURSING TUJUAN (SMART) NURSING PLAN RATIOAL

DIAGNOSES

1 Nutritional imbalance After nursing actions for 2x24 NIC: Nutrition NIC: Nutrition
is less than the body's hours, nursing problems are management management
needs. resolved by the results criteria: 1. Determine the 1. So that patients
NOC: Nutritional nutritional patient's nutritional want to consume
Definition: Nutritional status status and ability to food according to
intake is not enough to No Indikator A T meet nutritional their needs and
meet metabolic needs 1 Nutrition intake 5 needs abilities
2 Food intake 5 2. Determine the 2. To determine the
Limitation of 3 Fluid intake 5 number of calories number of calories
characteristics: 4 Energy 5 and the type of according to the
1. Weight 20% or nutrition needed patient's condition
more below the Indicator scale: 3. Offer nutritious 3. So that the patient's
ideal weight range 1. Very deviates from the normal dense snacks. appetite increases
2. Hyperactive bowel range 4. Monitor nutritional 4. To find out the
sounds 2. Many deviate from the normal intake patient's nutrition
3. Quickly full after range 5. Determine what is 5. So that patients
eating 3. Enough to deviate from the the food reference for know what food to
4. Diarrhea normal range the patient consume
5. Taste sensation 4. Slightly deviates from the
disorders normal range
6. Inability to eat food

24
 7. Abdominal pain 5. Does not deviate from the
8. Mucous membranes normal range
9. Pale
10. Uninformed
11. Weight loss with
adequate food
intake

Related faculty:
1. Biological factors
2. Economic factors
3. Psychosocial
disorders

2 Acute pain After nursing actions for 2x24 NIC: Pain management NIC: Pain
hours, nursing problems are 1. Perform a management
Definition: An resolved by the results criteria: comprehensive pain 1. To find out the
unpleasant sensory or NOC: Pain control assessment patient's PQRST
social experience arising 2. Observation of non 2. To feel whether the
from actual or potential No Indikator A T verbal instructions patient is
tissue damage or 1 Recognize when 5 regarding discomfort comfortable with
described as damage pain occurs 3. Use therapeutic the situation
(international 2 Describes the 5 communication 3. Provide therapy to
association for the study disease factor strategies improve the
of pain), sudden or slow 3 Using precautions 5 4. Dig patient patient's health
onset of mild to severe 4 Recognize what is 5 knowledge about status
intensity with an end related to pain pain 4. To find out how
that can be anticipated symptoms patients know about
or predicted pain

25
 Indicator scale: 5. Control 5. So that patients are
Limitation of 1. Never shows environmental not disturbed by
characteristics: 2. Rarely show factors temperature, noise
1. Proof of pain by 3. Sometimes showing and light
using a standard pain 4. Often shows
checklist for patients 5. Consistently showing
who cannot express
it
2. Diaphoresis
3. Pupillary dilatation
4. Painful facial
expressions (e.g., the
eyes are less
luminous, look
chaotic, eye
movements radiate
or remain in one
focus, grimace.)
5. Narrowing focus
(eg, perception of
time, thought
processes,
interactions with
people and the
environment)
6. Focus on yourself
7. Complaints about
intensity using a

26
 standard scale of
pain
8. Complaints about
pain characteristics
using standard pain
instruments
9. Report on pain
behavior / activity
change

Related factors
1. Biological injury
agent (infection,
ischemia, neoplasm)
2. Physical injury
agents (eg,
absenteeism,
amputation, burns,
cuts, heavy lifting,
surgical procedures,
trauma, excessive
exercise)
3. Chemical injury
agents (burns,
capsaicin,
methylene chloride,
mustard agents)

27
3 Knowledge Deficit After nursing actions for 2x24 NIC: Teaching : the NIC: Teaching : the
hours, nursing problems are disease process disease process
Definition : Absence or resolved by the results criteria: 1. Assess the patient's 1. Helping patients to
deficiency of cognitive NOC: Knowledge : Management level of knowledge understand
information related to a of acute illness tied to specific information related
particular topic disease processes to the disease
No Indikator A T 2. Consider patient process specifically
Limitation of 1 Factor of 5 learning needs 2. Planning,
Characteristics contributing 3. Inform patients and implementing, and
1. Inaccuracies in factors and factors families to schedule evaluating teaching
carrying out tests stairs, time and programs designed
2. Inaccuracies 2 The course of 5 location of surgery to address patient
following orders disease is usually 4. Monitor patient's specific needs
3. Lack of knowledge physical and 3. Helping patients to
4. Inappropriate 3 Specific 5 psychological understand and
behavior (eg, characteristics of limitations and prepare patients
hysteria, hostility, disease background and mentally before
agitation, apathy) culture surgery and after
4 Drug side effects 5 5. Instruct the patient surgery
Related factors about the purpose 4. Prepare the patient
1. Impaired cognitive 5 Strategies for 5 and work of each to achieve or
function controlling pain drug maintain the level
2. Memory disorders of exercise that is
3. Lack of information applied
4. Less interest in Indicator scale: 5. Prepare patients to
learning 1. No knowledge use prescription
5. Lack of knowledge 2. Limited knowledge drugs safely and
resources 3. Medium knowledge monitor the effects
6. Misunderstanding of 4. A lot of knowledge of these drugs

28
 5. Very much knowledge
4 Risk of aspiration After nursing actions for 2x24 NIC: Prevention of NIC: Prevention of
hours, nursing problems are aspiration aspiration
Definition: resolved by the results criteria: 1. Position the patient 1. Facilitate patency
The range undergoes NOC: Respiratory status to maximize of the airway
gastrointestinal ventilation 2. Preventing or
secretion, secretion of 2. Monitor the level of minimizing risk
oropharynx, liquid or No Indikator A T consciousness, factors in patients
solid matter into the 1 Respiratory 5 cough reflex, reflex who are at risk of
tracheobronical tract, frequency gag, swallowing experiencing
which can interfere with ability aspiration
health. 2 Respiratory 5 3. Monitor oxygenation 3. Improve the well-
Rhythm status being of
Risk factor : 4. Give oxygen physiological and
1. The presence of an 3 Oxygen 5 properly psychological
oral / nasal tube (eg saturation 5. Monitor speed, functions
trachea, feeding rhythm, depth and 4. Monitor and
tube). difficulty breathing manage patients
2. Empty stomach 4 Inspiration depth 5 who have just been
emptying done general or
3. Increase in gastric 5 Identifying risk 5 local anesthesia
residue factors 5. Ensure airway and
4. Increased adequate gas
intragastric exchange
5. Decreased Indicator scale:
gastrointestinal 1. Very deviates from the normal
motility range
6. Decreased vomiting 2. Many deviate from the normal
reflex range

29
7. Decreased level of 3. Enough to deviate from the
consciousness normal range
8. Rigid jaw 4. Slightly deviates from the
9. Esophageal normal range
sphincter under 5. Does not deviate from the
incompetent normal range

30
31
 CHAPTER IV
FINILITY

A. Conclusion
Achalasia is a rare disease of the esophageal muscle (the tube that swallows).
The term achalasia means "failure to relax" and refers to the inability of the lower
esophageal sphincter (muscle ring between the lower esophagus and stomach) to
open and let food pass into the stomach. As a result, patients with achalasia have
difficulty swallowing food.
The etiology of achalasia is not known exactly. However, there is evidence
that the Auerbach plexus degeneration causes loss of neurological regulation.
Some theories that develop are related to autoimmune disorders, infectious
diseases or both.

B. Suggestion
This paper may be useful for readers, especially students. There are also
suggestions that we do:
1. For educational institutions
It is expected that the academic parties provide guidance to students,
especially in nursing theory and practice.
2. For Students
It is expected to increase knowledge about theory and nursing care in
Acalacia patients so that in the future they can also understand nursing care as
a whole.

32
 BIBLIOGRAPHY

Bakry F. 2006. Akalasia. Buku ajar ilmu penyakit dalam. Pusat Penerbitan,
Departemen Ilmu penyakit Dalam Fakultas Kedokteran Universitas Indonesia.
Jakarta.

Irwan. 2009. Akalasia Esofagus. http://www.emedicine.com/radio/topic6.htm. Di

akses Maret 2019

Ismail, Ali. 2001. Buku Ajar Ilmu Penyakit Dalam Jilid ll Edisi Ketiga. Jakarta: Balai
Penerbit FKUI

Nelson. 2005. Ilmu Kesehatan Anak Volume 2 Jakarta: EGC

Patel, Pradip R. 2006. RadiologiEd 2. Jakarta: Salemba PT. Gelora Aksara Pratama.

Priyanto, el al. 2008. Endoskopi Gastrointestinal. Jakarta: Salemba Medika

wikipedi.org. 2007. Achalasia. http://en.wikipedi.org/wiki/achalasia. Di Akeses

Maret 2019

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