nursing care plan for upper gastrointestinal bleeding ncp

7/25/2019 Nursing Care Plan for Upper Gastrointestinal Bleeding NCP

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Student Nurses Community

NURSING CARE PLAN Upper Gastrointestinal Bleeding

ASSESSMEN !IAGN"SIS IN#ERENCE PLANNING INER$ENI"N RAI"NALE E$ALUAI"N

SUBJECTIVE:

Napakasakit ngtiyan ko (Imhaving severestomach pain) asverbalie! by t"epatient#

$BJECTIVE:

%b!o&inalg'ar!ing

igi! bo!y

post're

a*ial

gri&a*ing

V+S taken as

,ollo-s

T: ./#.0C1: 23: 43B1: 445+ 25

%*'te or*"roni* pain

&aybe relate!to *"e&i*alb'rn o, gastri*&'*osa6 oral*avity an!p"ysi*alresponse s'*"as ,le7 &'s*lespas& in t"esto&a*" -all#

%*i!6 pepsin6 an!"eli*oba*ter

in,e*tion play ani&portant role int"e !evelop&ento, gastri* 'l*ers#T"e gastri*&'*osal barrieroverlies t"eepit"eli' T"ese*retion o,&'*'s an!bi*arbonate

provi!es a ,irstline !e,ense in&aintaining anear8nor&al p9on t"e gastri*epit"eli'& an!prote*ts t"e&'*osal barrieragainst a*i!#astro&'*osalprostaglan!ins

in*rease t"ebarrier;sresistan*e to'l*eration# T"eintegrity o, t"ebarrier isen"an*e! by t"eri*" bloo! s'pplyo, t"e &'*osa o,t"e sto&a*" an!!'o!en'

%,ter < "o'rs o,n'rsing

interventions6 t"e1atient verbalierelie, o, pain an!!e&onstraterela7e! bo!ypost're an! beable to sleep orrest properly#

Independent

Note reports o,

pain6 in*l'!inglo*ation6 !'ration6an! intensity (5845s*ale)#

evie- ,a*tors t"at

aggravate oralleviate pain#

Note nonverbal

pain *'es#

1rovi!e s&all

,re='ent &eals#

I!enti,y an! li&it

,oo!s t"at *reate!is*o&,ort#

%ssist -it" a*tive

an! passive range

o, &otione7er*ises#

1rovi!e ,re='ent

oral *are an!*o&,ort &eas'resin*l'!ing ba*k r'ban! position*"ange#

1ain is not al-ays

present6 s"o'l!be *o&pare! -it"patient;s previo'spain sy&pto&s#T"e *o&parison&ay assist in!iagnosis o,etiology o,blee!ing an!!evelop&ent o,*o&pli*ations#

9elp,'l in

establis"ing!iagnosis an!treat&ent nee!s#

Non8verbal *'es

&ay be bot"p"ysiologi*al an!psy*"ologi*al an!

&ay be 'se in*on>'n*tion -it"verbal *'es toeval'ate e7tentan! severity o,t"e proble

oo! "as an a*i!8

ne'traliing e,,e*tan! !il'tes t"egastri* *ontents#

%,ter < "o'rs o,n'rsing

interventions6 t"e1atient -as able toverbalie relie, o,pain an!!e&onstrate rela7e!bo!y post're an! beable to sleep or restproperly#
http://nursingcrib.com/http://nursingcrib.com/


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Colla%orati&e

1rovi!e an!

i&ple&ent !ietary&o!i,i*ations#

Use reg'lar t"an

ski& &ilk6 i, &ilk isallo-e!#

%!&inister

&e!i*ations asin!i*ate! s'*" asanalgesi*s#

S&all &ealsprevent !istentionan! t"e release o,gastrin#

Spe*i,i* ,oo!s t"at

*a'se !istressvary a&ongin!ivi!'als# Spi*y,oo!s6 al*o"ol6an! *o,,ee *anpre*ipitate!yspepsia#

e!'*es >oint

sti,,ness6&ini&iing painan! !is*o&,ort#

9alitosis ,ro&

stagnant oralse*retions is'nappetiing an!*an aggravatena'sea#

Client &ay re*eive

not"ing by &o't"initially# ?"enoral intake isallo-e!6 ,oo!*"oi*es !epen!on t"e !iagnosisan! etiology o,t"e blee!ing#


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at in reg'lar &ilk

&ay !e*reases

gastri*se*retions# T"e*al*i'& an!protein *ontentespe*ially in ski&&ilk in*reasesse*retions#

9elps relive a*'te

or severe pain#

nursing care plan for upper gastrointestinal bleeding ncp

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